Showing papers in "American Journal of Geriatric Psychiatry in 2005"
TL;DR: Preliminary support is provided that rosiglitazone may offer a novel strategy for the treatment of cognitive decline associated with AD, consistent with recent reports that plasma Aβ42 decreases with progression of AD.
Abstract: Objective Insulin resistance (impaired insulin action) has been associated with Alzheimer disease (AD) and memory impairment, independent of AD. Peroxisome proliferator-activated receptor-γ (PPAR-γ) agonists improve insulin sensitivity and regulate in-vitro processing of the amyloid precursor protein (APP). Authors evaluated the effects of the PPAR-γ agonist rosiglitazone on cognition and plasma levels of the APP derivative β-amyloid (Aβ) in humans. Methods In a placebo-controlled, double-blind, parallel-group pilot study, 30 subjects with mild AD or amnestic mild cognitive impairment were randomized to a 6-month course of rosiglitazone (4 mg daily; N = 20) or placebo (N = 10). Primary endpoints were cognitive performance and plasma Aβ levels. Results Relative to the placebo group, subjects receiving rosiglitazone exhibited better delayed recall (at Months 4 and 6) and selective attention (Month 6). At Month 6, plasma Aβ levels were unchanged from baseline for subjects receiving rosiglitazone but declined for subjects receiving placebo, consistent with recent reports that plasma Aβ42 decreases with progression of AD. Conclusions Findings provide preliminary support that rosiglitazone may offer a novel strategy for the treatment of cognitive decline associated with AD. Future confirmation in a larger study is needed to fully demonstrate rosiglitazone's therapeutic potential.
526 citations
TL;DR: Clinicians should be aware of the high rates of anxiety as well as depressive symptoms in family caregivers of people with AD, especially in female caregivers, and a poor-quality relationship between the caregiver and the CR predicts both caregiver depression and anxiety.
Abstract: Objective There are high rates of stress, distress, and psychological illness in family caregivers of people with dementia. Female caregivers and those caring for people with neuropsychiatric symptoms are particularly at risk. The authors report on the prevalence of anxiety and depression in a sample of family caregivers of people with Alzheimer disease (AD) and compare the characteristics of those who did or did not have those conditions. Methods A group of 153 people with AD and their caregivers were interviewed as part of a larger study of AD. Results In all, 23.5% of caregivers scored at or above caseness level for anxiety, and 10.5%, at levels for depression. Care-recipient (CR) activities of daily living (ADL) impairment, being a caregiver living with the CR, being a female caregiver, reporting a poorer quality of relationship with the CR, and caregivers reporting their health as being poor all predicted anxiety disorder. CR irritability, caregivers reporting poor health, and a poorer quality of relationship with the CR predicted depression. Conclusions Clinicians should be aware of the high rates of anxiety as well as depressive symptoms in family caregivers of people with AD, especially in female caregivers. CRs and Caregivers' impaired physical health put them at risk for psychological morbidity and should be treated energetically. A poor-quality relationship between the caregiver and the CR predicts both caregiver depression and anxiety. Caregivers living with the CR are much more likely to be anxious than depressed.
412 citations
TL;DR: Preliminary support is provided that rosiglitazone may offer a novel strategy for the treatment of cognitive decline associated with AD, consistent with recent reports that plasma Abeta42 decreases with progression of AD.
Abstract: Objective Insulin resistance (impaired insulin action) has been associated with Alzheimer disease (AD) and memory impairment, independent of AD. Peroxisome proliferator-activated receptor-γ (PPAR-γ) agonists improve insulin sensitivity and regulate in-vitro processing of the amyloid precursor protein (APP). Authors evaluated the effects of the PPAR-γ agonist rosiglitazone on cognition and plasma levels of the APP derivative β-amyloid (Aβ) in humans. Methods In a placebo-controlled, double-blind, parallel-group pilot study, 30 subjects with mild AD or amnestic mild cognitive impairment were randomized to a 6-month course of rosiglitazone (4 mg daily; N=20) or placebo (N = 10). Primary endpoints were cognitive performance and plasma Aβ levels. Results Relative to the placebo group, subjects receiving rosiglitazone exhibited better delayed recall (at Months 4 and 6) and selective attention (Month 6). At Month 6, plasma Aβ levels were unchanged from baseline for subjects receiving rosiglitazone but declined for subjects receiving placebo, consistent with recent reports that plasma Aβ42 decreases with progression of AD. Conclusions Findings provide preliminary support that rosiglitazone may offer a novel strategy for the treatment of cognitive decline associated with AD. Future confirmation in a larger study is needed to fully demonstrate rosiglitazone's therapeutic potential.
364 citations
TL;DR: It is suggested that identifying and treating neuropsychiatric symptoms in AD may improve both patient and caregiver QOL.
Abstract: Objective Authors examined the impact of neuropsychiatric symptoms in Alzheimer disease (AD) patients' and caregivers' quality of life (QOL) and assessed the relationship of caregiver distress to neuropsychiatric symptoms and caregiver QOL. Methods Sixty-two patients with probable or possible AD and their caregivers participated. Neuropsychiatric symptoms of patients were assessed with the Neuropsychiatric Inventory (NPI). QOL of both patients and caregivers was assessed using the QOL–Alzheimer's Disease (QOL–AD) scale. Each patient and caregiver completed patient QOL ratings; caregivers also completed caregiver QOL assessments. Results Caregiver QOL–AD was negatively correlated with agitation/aggression, anxiety, disinhibition, irritability/lability, and total NPI score. Patient QOL on both patient and caregiver ratings was negatively correlated with depression. Patient-reported QOL–AD ratings at different levels of cognitive functioning were not correlated with caregiver-reported ratings. The lack of relationship between patient and caregiver assessments of patient QOL was evident in both mildly and moderately affected patients. Caregiver QOL was negatively correlated with distress related to agitation/aggression, disinhibition, irritability/lability, and total NPI distress. Conclusion Neuropsychiatric symptoms of AD patients adversely affect both patient and caregiver QOL. These results suggest that identifying and treating neuropsychiatric symptoms in AD may improve both patient and caregiver QOL.
259 citations
TL;DR: This review summarizes existing epidemiological studies of the defined clinical predementia syndromes and their progression to dementia and concludes that Mild Cognitive Impairment definition is less consistent in population-based studies than clinical studies, in which progression to AD is also more consistent.
Abstract: A variety of clinically-defined predementia syndromes, with differing diagnostic criteria and nomenclature, have been proposed to describe nondisabling symptomatic cognitive deficits arising in elderly persons. Incidence and prevalence of different predementia syndromes vary as a result of different diagnostic criteria, sampling, and assessment procedures. The incidence rates of all predementia syndromes increase with age and are higher in subjects with less education; but age, educational background, and gender are not consistently related to prevalence rates. There is particular interest in "Mild Cognitive Impairment (MCI)" because this predementia syndrome is thought to be a prodromal phase of Alzheimer disease (AD). Several studies have suggested that most patients who meet MCI criteria will progress to AD, but rates of conversion to AD and dementia vary widely among studies. Furthermore, MCI definition is less consistent in population-based studies than clinical studies, in which progression to AD is also more consistent. To clarify the sources of discrepant findings in the literature, this review summarizes existing epidemiological studies of the defined clinical predementia syndromes and their progression to dementia.
255 citations
TL;DR: Although there are no pharmacological treatments at present that are capable of delaying the long-term progression of MCI to dementia, there is some evidence of short-term symptomatic benefits with acetylcholinesterase inhibitors.
Abstract: Mild cognitive impairment (MCI) describes a state of cognitive functioning that is below defined norms, yet falls short of dementia in severity. It exists across a cognitive continuum with borders that are difficult to define precisely. Within our "graying" western societies, its prevalence increases with age. A number of subtypes of MCI, including age-associated memory impairment (AAMI), age-associated cognitive decline (AACD), amnestic MCI (MCIa), and cognitive impairment not dementia (CIND) have contributed to our understanding of MCI. Recent efforts have been directed at developing a uniform diagnostic classification for MCI that reflects the maturation of knowledge about this state. There is considerable etiological and clinical heterogeneity within MCI; however, there is a unifying increased risk of progression to dementia. The diagnostic process for MCI involves assessment of multiple cognitive domains, with particular attention to episodic and semantic memory, while neuroimaging with structural MRI and PET both add to the diagnostic and prognostic evaluation of MCI. Although there are no pharmacological treatments at present that are capable of delaying the long-term progression of MCI to dementia, there is some evidence of short-term symptomatic benefits with acetylcholinesterase inhibitors. MCI is an important clinical problem, which clinicians can expect to face with increasing frequency. The essentials of management include a thorough assessment directed at etiological determination and counseling and judicious use of available therapeutics.
226 citations
TL;DR: Depressive and apathetic symptoms were the earliest to appear, and hallucinations, elation/euphoria, and aberrant motor behavior were the latest symptoms to emerge, and potentially treatable neuropsychiatric symptoms are common in AD and represent a major source of distress among caregivers.
Abstract: Objectives The behavioral and psychological symptoms of Alzheimer's disease (AD) are associated with significant patient and caregiver distress and increased likelihood of institutionalization. We attempted to characterize in detail these symptoms and the distress they cause to caregivers. Methods Patients with probable AD were assessed with the Mini-Mental State Exam (MMSE), Functional Assessment Staging (FAST), and the Neuropsychiatric Inventory With Caregiver Distress (NPI–D). Results Four hundred and thirty-five patients were recruited. Neuropsychiatric symptoms of all types were highly prevalent. The most common and most persistent symptom was apathy (75%). Delusional symptoms were the least persistent. Depressive and apathetic symptoms were the earliest to appear, and hallucinations, elation/euphoria, and aberrant motor behavior were the latest symptoms to emerge. Hallucinations were significantly more common in severe dementia. Symptoms of irritability were most prevalent in early disease. Total Neuropsychiatric Symptom score was significantly correlated with MMSE and FAST score. Caregivers rated their own emotional distress levels as moderate or severe for 10 out of 12 symptom domains. The sum total of caregiver distress was strongly correlated with total NPI–D but not cognition or functional state. Distress levels did not vary when analyzed according to the patients' place of residence. Conclusions Potentially treatable neuropsychiatric symptoms are common in AD and represent a major source of distress among caregivers. The extent of neuropsychiatric symptomatology is seen to correlate with the level of functional and cognitive disability although some symptoms are variably persistent and related to disease stage.
208 citations
TL;DR: Tailored models of attention and executive function in the preclinical phase of AD in old age support theoretical models of neuropsychological processes before AD onset and significantly predicted incident AD over and above age, gender, and education.
Abstract: Objective Longitudinal studies of neuropsychological changes in the preclinical phase of Alzheimer disease (AD) have yielded mixed results. Although some studies report tests of episodic memory, others report tests of attention and executive functions as reliable predictors of subsequent AD. Following theoretical models of neuropsychological processes before AD onset, the authors examined the predictive value of attention and executive function in the preclinical phase of AD in old age. Methods Authors studied the cognitive performance of 187 initially normal participants of the Berlin Aging Study, a community-based representative sample of Berlin citizens age 70 to 103, over a period of 4 years. Tests of attention and executive function (Digit Letter Test, Trailmaking Part B Test, Digit Symbol Substitution Test, and Identical Pictures Test) and of learning and recall functions (Activity Recall, Memory for Text, and Paired-Associate Learning) were administered at baseline. Diagnosis of AD was made according to NINCDS-ADRDA criteria (probable AD). Receiver operating characteristics curve analyses and Cox regression analyses were used to assess the diagnostic accuracy and predictive value of the neuropsychological tests at baseline for incident AD after 4 years. Results After 4 years, 15 participants had developed AD. Tests of attention and executive function discriminated best between nonconverters and incident AD cases. A similar pattern was found in survival analyses; attention and executive function tests, together with tests of learning and recall, significantly predicted incident AD over and above age, gender, and education. Conclusion These results support theoretical models of attention and executive function in the preclinical phase of AD in old age.
196 citations
TL;DR: This pilot study was unable to demonstrate a benefit for donepezil in preventing or treating delirium in a relatively young and cognitively-intact group of elderly patients undergoing elective orthopedic surgery.
Abstract: Objective Delirium is a frequent complication of major surgery in older persons. The authors evaluated the possible benefit of donepezil versus placebo in the prevention and treatment of postoperative delirium in an older population without dementia undergoing elective total joint-replacement surgery. Methods A sample of 80 patients participated in this randomized, double-blind, placebo-controlled trial of donepezil. Each participant was evaluated before surgery and then received donepezil or placebo for 14 days before surgery and 14 days afterward. Postoperative delirium was assessed with the Delirium Symptom Interview, Confusion Assessment Method, daily medical record, nurse-observation reviews, and DSM-IV diagnostic criteria for delirium. Subsyndromal delirium was also assessed for each participant. Results Delirium, diagnosed by DSM-IV criteria, was found on at least 1 postoperative day in 18.8% of subjects, but there were no significant differences between the donepezil and placebo groups. When delirium was present, it lasted only 1 day, and there was no difference between the groups. Subsyndromal delirium was found on at least 1 postoperative day for 68.8% of subjects, and, when this occurred, lasted 2 days or less, on average. There was no difference between the groups in the occurrence or duration of subsyndromal delirium. There was no difference between the groups in disposition to home or to another facility. Conclusions This pilot study was unable to demonstrate a benefit for donepezil in preventing or treating delirium in a relatively young and cognitively-intact group of elderly patients undergoing elective orthopedic surgery. Furthermore, postoperative delirium was not a major problem in this population.
195 citations
TL;DR: A pattern of temporal sequencing was established, with anxiety often progressing to depression or depression with GAD, and the co-occurrence of these represents more severe and more chronic psychopathology, associated with longstanding vulnerability in elderly persons.
Abstract: Objective The authors sought to establish the natural course and risk-profile of depression, generalized anxiety disorder (GAD), and depression with co-existing GAD in later life. Methods A total of 2,173 community-living elderly persons were interviewed at baseline, and at a 3-year follow-up. The course of "pure" depression, "pure" GAD, and depression with coexisting GAD was studied in 258 subjects with baseline psychopathology. Authors assessed bivariate and multivariate relationships between risk factors and course types. The risk-profile for onset of pure depression, pure GAD, and the mixed condition at follow-up was studied in 1,915 subjects without baseline psychopathology. Results Remission rate at follow-up was 41% for subjects with depression-only, 48% for pure GAD, and significantly lower (27%) for depression with coexisting GAD. A pattern of temporal sequencing was established, with anxiety often progressing to depression or depression with GAD. Onset of pure depression and depression with co-existing GAD was predicted by loss events, ill health, and functional disability. Onset of pure GAD, and, more strongly, that of depression with coexisting GAD, was associated with longstanding, possibly genetic vulnerability. Conclusions In comparison with either depression-only or anxiety-only, the co-occurrence of these represents more severe and more chronic psychopathology, associated with longstanding vulnerability. In elderly persons, GAD often progresses to depression or to the mixed condition. These findings mostly favor a dimensional, rather than a categorical, classification of anxiety and depression.
189 citations
TL;DR: Normal sleep-wake regulation is dependent upon an oscillatory circadian rhythm promoting alertness and sleep at appropriate times of day and changes in endogenous circadian rhythm in pAD were consonant with those seen in normal aging and also observed changes that were apparently discrete from those seenin normal aging.
Abstract: Objective Normal sleep–wake regulation is dependent upon an oscillatory circadian rhythm promoting alertness and sleep at appropriate times of day. Circadian rhythms have been noted to be disturbed as a consequence of both normal aging and age-associated pathologies like Alzheimer disease (AD). However, the relationship between the consequences of normal versus pathological aging upon circadian regulation remains unclear. The authors evaluated the similarities and differences between the consequences of aging and AD on endogenous circadian rhythm. Methods Authors measured locomotor activity and, with a constant routine protocol, core body temperature, examining differences and similarities in circadian disturbances in groups of normal elderly and patients with probable AD (pAD), as compared with a comparison group of young, normal volunteers, measuring endogenous circadian amplitude (ECA) and endogenous circadian phase (ECP) of core body temperature, and made parametric and nonparametric assessments of locomotor activity rhythms. Results The ECP of core body temperature was delayed in patients with pAD versus both normal young and normal elderly subjects, whereas the ECA was reduced both in normal elderly and pAD subjects compared with a comparison group of young subjects. There was also disassociation of the activity and core body temperature rhythms in both age groups versus the young subjects. Conclusions Authors observed changes in endogenous circadian rhythm in pAD that were consonant with those seen in normal aging (amplitude reduction; loss of phase coordination) and also observed changes that were apparently discrete from those seen in normal aging (phase delay).
TL;DR: Poorer self-rated health, lower perceived adequacy of social support, decreased feelings of self-efficacy, and a past history of depression increased the odds of both a subthreshold and major depression, versus no depression, but greater functional disability and experiencing a negative life event were significant only for a subThreshold depression.
Abstract: Objective Authors examined the potential risk factors of major and subthreshold depression among elderly persons seeking rehabilitation for age-related vision impairment. Methods Participants (N = 584), age 65 and older, with a recent vision loss, were new applicants for rehabilitation services. Subthreshold depression was defined as a depressive syndrome not meeting criteria for a current major depression (i.e., minor depression, major depression in partial remission, dysthymia) or significant depressive symptomatology. Results Seven percent of respondents had a current major depression, and 26.9% met the criteria for a subthreshold depression. Poorer self-rated health, lower perceived adequacy of social support, decreased feelings of self-efficacy, and a past history of depression increased the odds of both a subthreshold and major depression, versus no depression, but greater functional disability and experiencing a negative life event were significant only for a subthreshold depression. Only a history of past depression was significant in increasing the odds of having a major versus a subthreshold depression. Conclusion Results highlight similarities in characteristics of, and risk factors for, subthreshold and major depression. Future research is needed to better understand both the trajectory and treatment of subthreshold depression, relative to major depressive disorders.
TL;DR: This study suggests that anxiety has a curvilinear relationship with cognition, whereas depressive symptoms, however, were always negatively associated with cognitive performance.
Abstract: Objective: The authors investigated the relationship between anxiety and cognition in older persons, taking account of comorbid depression. Methods: Data were used from the Longitudinal Aging Study Amsterdam (LASA), a large epidemiological study of 3,107 elderly citizens in The Netherlands. Anxiety and depression were measured with the Hospital Anxiety and Depression Scale-Anxiety subscale and the Center for Epidemiologic Studies-Depression Scale. In measuring cognitive performance, general cognitive functioning was measured by means of Mini-Mental State Exam, episodic memory was measured with the Auditory Verbal Learning Test (AVLT), fluid intelligence by using the RAVEN, and information-processing speed by the coding task. Analysis of variance examined the association between anxiety symptoms and cognition in persons with and without depression. Results: Main effects of anxiety symptoms were found for learning and delayed recall of the AVLT. Depression symptoms showed significant main effects on almost all cognitive performance tests. Mild anxiety symptoms were associated with better cognitive performance, whereas severe anxiety symptoms were negatively associated with cognitive functioning. In contrast, depressive symptoms showed a linear association with cognition; more depression was associated with worse cognition. Conclusion: This study suggests that anxiety has a curvilinear relationship with cognition. Depressive symptoms, however, were always negatively associated with cognitive performance.
TL;DR: The incidence of suicide among older men with prostate cancer is higher than previously recognized and screens for depression and suicide should be done after diagnosis and redone during the first 6 months regularly, particularly in the primary-care setting.
Abstract: Objective The authors sought to determine the incidence of suicide and its relevant correlates among men with prostate cancer. Methods This was a population-based, retrospective cohort review of men age 65 and older, residing in South Florida between 1983 and 1993. Average annual suicide rate was calculated for prostate cancer-related suicides and contrasted with age and gender-specific rates in the same geographic area. Results Of 667 completed suicides, 20 were prostate cancer-related (3% of the total male suicide sample). The average annual incidence of suicide for men was 55.32 per 100,000 persons, but for men with prostate cancer, the rate was 274.7 per 100,000. The risk of suicide in men with prostate cancer was 4.24 times that of an age- and gender-specific cohort. The clinical correlates included depression (70%), cancer diagnosis within 6 months of suicide (80%), physician visit within 1 month of suicide (60%), and being foreign-born (70%). Conclusion The incidence of suicide among older men with prostate cancer is higher than previously recognized. Depression, recent diagnosis, pain, and being foreign-born are important clinical correlates. Screens for depression and suicide in older men with prostate cancer should be done after diagnosis and redone during the first 6 months regularly, particularly in the primary-care setting. Public education is needed to decrease the stigma associated with having a cancer diagnosis.
TL;DR: Affective variables had a stronger association with fear of falling than non-affective variables in a hospital-based group of subjects, and further research is needed to determine whether similar findings occur in a community-based sample of older people.
Abstract: Objective Fear of falling is common in older people, occurring on average in 50% of those who have fallen in the previous year. Little is known about the psychological correlates of fear of falling. The purpose of this study was to determine whether clinically significant depression and anxiety were independently associated with fear of falling. Methods This was a cross-sectional study of 105 persons age ≥60 years, admitted to medical or orthopedic wards, who had fallen at least once in the previous 12 months. Fear of falling was assessed using two different constructs: 1) intensity of fear; and 2) self-efficacy. Depressive and anxiety disorders were assessed with the Structured Clinical Interview for DSM-IV. Depression and anxiety severity were assessed with the Hospital Anxiety and Depression Scale. Demographic, physical, functional, and social variables previously found to be associated with fear of falling were also measured. Logistic-regression and multiple-regression analyses were used to examine the independent association of affective variables with fear of falling. Results Depressive disorders, anxiety disorders, depression severity, and anxiety severity had significant independent associations with both constructs of fear of falling. Of all the variables that were measured, depressive disorders and depression severity had the strongest associations with fear of falling. Conclusion Affective variables had a stronger association with fear of falling than non-affective variables in a hospital-based group of subjects. Further research is needed to determine whether similar findings occur in a community-based sample of older people.
TL;DR: The hallmark neuropathophysiological changes that occur in PD plus the association between exposure to dopaminergic medications and certain psychiatric disorders suggest a neurobiological basis for most psychiatric symptoms, although psychological factors are probably involved in the development of affective disorders.
Abstract: Although Parkinson disease (PD) is primarily considered a movement disorder, the high prevalence of psychiatric complications suggests that it is more accurately conceptualized as a neuropsychiatric disease. Affective disorders, cognitive impairment, and psychosis are particularly common in PD and are associated with excess disability, worse quality of life, poorer outcomes, and caregiver distress. Yet, in spite of this and their frequent occurrence, there is incomplete understanding of the epidemiology, phenomenology, risk factors, neuropathophysiology, and optimal treatment strategies for these disorders. Psychiatric complications are typically comorbid, and there is great intra- and inter-individual variability in presentation. The hallmark neuropathophysiological changes that occur in PD plus the association between exposure to dopaminergic medications and certain psychiatric disorders suggest a neurobiological basis for most psychiatric symptoms, although psychological factors are probably involved in the development of affective disorders. Although antidepressants, antipsychotics, and cognition-enhancing agents are commonly prescribed in PD, controlled studies demonstrating efficacy and tolerability of these drugs are virtually nonexistent. Because of the high prevalence and complexity of psychiatric complications in PD, geriatric psychiatrists are in a position to offer valuable consultation and clinical care to this population. This article provides an overview of the epidemiology, pathophysiology, clinical presentation, and management of the most common psychiatric complications in PD.
TL;DR: This was a "failed study" (i.e., neither active treatment was superior to placebo), and the efficacy results should, therefore, be interpreted with caution.
Abstract: Objective Management of depression in elderly patients presents a significant medical challenge, and there is a need for further clinical trials. The authors examined the efficacy and tolerability of escitalopram and fluoxetine versus placebo in the treatment of elderly patients with major depressive disorder (MDD). Methods This was an 8-week, randomized, double-blind comparison of the efficacy and tolerability of escitalopram (10 mg/day) and fluoxetine (20 mg/day), to placebo in elderly patients with MDD. The prospectively defined primary efficacy parameter was the change from baseline in mean Montgomery-Asberg Depression Rating Scale (MADRS) total score at endpoint, using last observation carried forward. Results The intent-to-treat set comprised 517 patients; the escitalopram group included 173 patients; fluoxetine, 164 patients; and placebo, 180 patients. Mean age was 75 years, with a range of 65 to 93. Formally, this was a “failed study” (i.e., neither active treatment was superior to placebo), and the efficacy results should, therefore, be interpreted with caution. On the basis of the primary efficacy parameter, fluoxetine showed significantly lower efficacy than both escitalopram and placebo, which were not significantly different from each other. Rates of withdrawal because of adverse events/lack of efficacy were: placebo (2.8%/4.4%, respectively), escitalopram (9.8%/1.7%, respectively), and fluoxetine (12.2%/1.8%, respectively). No single adverse event occurred at an incidence ≥10% in escitalopram-treated patients. Conclusions Both escitalopram and fluoxetine were well tolerated by elderly patients with MDD. Neither demonstrated superior efficacy on primary endpoint versus placebo.
TL;DR: The prevalence rate of depression among older Chinese adults in Hong Kong is more or less similar to rates found in Western countries, and the data suggest that older adults who receive less social support are more likely to be depressed.
Abstract: Objective Because of the rapid aging of the population and inconsistent findings of previous epidemiological studies in Hong Kong, a prevalence study of depression among older adults was timely. The authors assessed the prevalence of depression among older adults and identified factors associated with it. Methods The authors interviewed a random representative sample of 917 community-dwelling Chinese adults age 60 and over. The 15-item Chinese Geriatric Depression Scale with a cutoff of ≥8 was used to identify clinically significant depression in the older adults. Results The authors found that 11.0% and 14.5% of older Chinese men and women, respectively, scored above the cutoff, a prevalence rate similar to those found in other countries, including the United States, England, and Finland. Factors that were associated with an increased likelihood of depression among older adults included poor self-rated health, long-term pain, vision problems, higher level of impairment in activities of daily living, residing in Hong Kong less than 20 years, financial strain, and having less social support. Conclusions The prevalence rate of depression among older Chinese adults in Hong Kong is more or less similar to rates found in Western countries. The data suggest that older adults who receive less social support are more likely to be depressed.
TL;DR: Complaints of cognitive decline are significantly associated with the severity of WML, independently of level of cognition and depression, and multiple linear regression showed that although the best correlate of SMC wasThe severity of depressive symptoms, SMC and WML were strongly correlated.
Abstract: Objectives Subjective memory complaints (SMC) and cerebral white-matter lesions (WML) are very prevalent among elderly subjects, but their clinical significance is controversial. The authors sought to determine whether SMCs are related to WML, independently of the presence of depressive symptoms, which are known to be associated with both. The relationship between SMC and cognition was also examined. Methods This is a cross-sectional study on 60 elderly subjects without dementia. All subjects underwent FLAIR and T 2 -weighted axial MRI scans, a memory-complaint questionnaire, a geriatric depression scale, and a comprehensive cognitive assessment. Results Multiple linear regression showed that although the best correlate of SMC was the severity of depressive symptoms, SMC and WML were strongly correlated. Objective cognitive performance was not significantly associated with SMC after adjusting for WML and mood. The presence of a history of late-onset depression was a strong correlate of WML severity, even after adjusting for age, gender, and education. Conclusions Complaints of cognitive decline are significantly associated with the severity of WML, independently of level of cognition and depression.
TL;DR: Among older, primary-care patients over the course of a 2-year follow-up interval, depression contributed as much to mortality as did MI or diabetes.
Abstract: Objective Depression is a major contributor to death and disability, but few follow-up studies of depression have been carried out in the primary-care setting. The authors sought to assess whether depression in older patients is associated with increased mortality after a 2-year follow-up interval and to estimate the population-attributable fraction (PAF) of depression on mortality in older primary-care patients. Methods Longitudinal cohort analysis was carried out in 20 primary-care practices. Participants were identified though a two-stage, age-stratified (60–74 or 75+) depression screening of randomly sampled patients; enrollment included patients who screened positive and a random sample of screened-negative patients. In all, 1,226 persons were assessed at baseline. Vital status at 2 years was the outcome of interest. Results Of 1,226 persons in the sample, 598 were classified as depressed. After 2 years, 64 persons had died. Persons with depression at baseline were more likely to die at the end of the 2-year follow-up interval than were persons without depression, even after accounting for potentially influential covariates such as whether the participant reported a history of myocardial infarction (MI) or diabetes. Conclusions Among older, primary-care patients over the course of a 2-year follow-up interval, depression contributed as much to mortality as did MI or diabetes.
TL;DR: Although an association between a subset of late-life depression and vascular disease is clear, significant gaps remain in understanding and further research is needed to establish the precise linkages and interactions between vascular disease and geriatric depression.
Abstract: Depression may occur as a result of vascular disease in a significant subpopulation of elderly persons. Indirect support for vascular disease as an underlying etiology of late-life depression includes the high rate of depression in patients with vascular disease, the frequency of "silent stroke" and white-matter hyperintensities in late-life depression, and the lower frequency of positive family histories of depression in such patients. The authors evaluate the associations of late-life depression with cerebrovascular disease by reviewing the existing pathophysiological, prognosis, and treatment-outcomes studies. Findings are based on review of the current literature systematically searched in electronic databases. Review of such studies indicates a high frequency of depression in older patients with cardiovascular and cerebrovascular diseases, and the possibility of a bidirectional relationship between depression and vascular disease. Studies examining patients with vascular depression have found that such patients have different symptom profiles, greater disability, and higher risk for poorer outcomes than those with nonvascular depression. Since the vascular depression hypothesis was proposed as a conceptual framework, evidence has accumulated that patients with vascular depression may have poorer outcomes that may be related in part to executive dysfunction and consequent disability. However, the association of vascular risk factors with geriatric depression has not been consistent in the studies to-date. Although an association between a subset of late-life depression and vascular disease is clear, significant gaps remain in our understanding. Further research is needed to establish the precise linkages and interactions between vascular disease and geriatric depression.
TL;DR: Depressed patients were less likely to self-report good adherence and had a lower median percentage of days with adequate medication coverage (on the basis of pharmacy refill data), according to patient report and pharmacy data.
Abstract: Objective Using various measures (electronic monitoring, patient/provider report, pharmacy data), the authors assessed the association between depression and diabetes medication adherence among older patients with Type 2 diabetes. Methods Patients completed a baseline survey on depression (Patient Health Questionnaire) and were given electronic monitoring caps (EMCs) to use with their oral hypoglycemic medication. At the time of the patient baseline survey, providers completed a survey on their patients' overall medication adherence. Upon returning the caps after 30 days, patients completed a survey on their overall medication adherence. EMC adherence was defined as percent of days out of 30 with correct number of doses. Using pharmacy refill data from the patient baseline through 1 year later, they defined adherence as the percentage of days with adequate medication, based on days' supply across refill periods. Results Of 203 patients (mean age: 67 years), 10% (N = 19) were depressed. Depressed patients were less likely to self-report good adherence and had a lower median percentage of days with adequate medication coverage (on the basis of pharmacy refill data). After adjustment for alcohol use, cognitive impairment, age, and other medication use, depression was still negatively associated with adequate adherence, according to patient report and pharmacy data. Depression showed no associated with adherence on the basis of provider or EMC data. Conclusions Depression was independently associated with inadequate medication adherence on the basis of patient self-report and pharmacy data.
TL;DR: Although the profiles of elderly suicide attempters and completers were similar, they could be distinguished by suicide intent, recent life events (particularly hospitalization), functional competence, religious denomination, and personality characteristics.
Abstract: Objective Attempted suicide in later life is under-researched despite its public health significance. In this study, the authors delineated the characteristics of elderly suicide attempters in a representative Chinese sample by comparing them with suicide completers and comparison subjects age 65 years or over who were randomly selected from the community. Methods There were 224 subjects in this study: 66 suicide attempters, 67 suicide completers, and 91 comparison subjects from the community. Using a case–control design and standardized measuring instruments, authors examined the risk and protective factors associated with attempted suicide, making direct comparisons with the community-comparison subjects and suicide completers. Results A current diagnosis of major depression was associated with a nearly 60-fold increased risk for attempted suicide, and a population attributable risk (PAR) of 67%. Other risk factors included past suicide attempts, poorer function of self-care, arthritis, and specific personality dispositions, particularly low Conscientiousness. Co-residence with children decreased risk. Although the profiles of suicide attempters and completers were similar, they could be distinguished by suicide intent, recent life events (particularly hospitalization), functional competence, religious denomination, and personality characteristics. Conclusions A high degree of clinical vigilance and multidisciplinary collaboration are required in the management of elderly suicide attempters. The treatment of depression should form a crucial part of the prevention program. Features that distinguish suicide completers from suicide attempters may also carry implications for the secondary prevention of suicide in elderly persons.
TL;DR: Although this review summarizes the scientific literature about the use of ECT generally, emphasis is given to describing literature pertaining to the treatment of geriatric patients when such information is available or when older patients or the disorders from which they suffer merit special consideration.
Abstract: Since its introduction in 1938, electroconvulsive therapy (ECT) has remained an important treatment for selected serious neuropsychiatric illnesses and continues to be one of the most effective treatments in psychiatry. ECT has evolved into a technically sophisticated procedure with a proven track record of safety. For this review, the authors relied heavily on the database from the APA Task Force Report on ECT (2001), updated with additional searches of computerized literature databases for the period 1999-2003. The review is necessarily a selective one, given the exponential growth of literature in the field. The authors attempt to summarize key areas of ECT practice, informed by relevant research findings and expert consensus when applicable. The authors also point out areas of controversy and gaps in our present knowledge. Although this review summarizes the scientific literature about the use of ECT generally, emphasis is given to describing literature pertaining to the treatment of geriatric patients when such information is available or when older patients or the disorders from which they suffer merit special consideration.
TL;DR: Elderly persons with lifetime GAD and MDD tend to have different onset and offset of the two disorders, characterize late-life GAD as a chronic disorder distinct from MDD.
Abstract: Objective Generalized anxiety disorder (GAD) in elderly persons is highly prevalent, but little is known about its course, age at onset, and relationship to comorbid major depressive disorder (MDD). The authors assessed the course and comorbidity of late-life GAD and MDD. Methods Authors assessed elderly subjects in anxiety or depression intervention studies who had a lifetime history of GAD, with current MDD (N=57) or without (N=46). Subjects' lifetime course of illness was charted retrospectively. Results The 103 subjects had a mean age of 74.1 years, and a mean age at onset of GAD of 48.8 years; 46% were late-onset. GAD episodes were chronic, and 36% were longer than 10 years. Of the comorbid GAD–MDD patients, most had different times of onset and/or offset of the disorders; typically, GAD preceded MDD. Conclusions Elderly subjects with GAD tended to have chronic symptoms lasting years-to-decades, without interruption, and many have late onset. Elderly persons with lifetime GAD and MDD tend to have different onset and offset of the two disorders. Findings characterize late-life GAD as a chronic disorder distinct from MDD.
TL;DR: Patients' neuropsychiatric functioning improved with olanzapine, risperidone, and placebo treatment, and there was a substantial response in the placebo group, and no significant differences emerged among treatments.
Abstract: Objective The authors compared efficacy of olanzapine versus placebo and risperidone as measured by the Neuropsychiatric Inventory and Clinical Global Impression–Severity of Psychosis scale in patients with dementia-related psychosis. Methods Patients with moderate-to-severe psychotic symptoms associated with dementia were recruited from outpatient or residential settings and randomly assigned to 10-week, double-blind, flexible-dose treatment with olanzapine (N = 204; 2.5 mg–10 mg/day; mean: 5.2 mg/day), risperidone (N = 196; 0.5 mg–2 mg/day; mean: 1.0 mg/day) or placebo (N = 94). Results Most measures of neuropsychiatric functioning improved in all treatment groups, including the placebo group, and no significant treatment differences occurred. Overall discontinuation was lowest in the placebo group, and the olanzapine group had a significantly higher incidence of discontinuation due to adverse events (16.2%) relative to placebo (3.2%) and risperidone (8.7%) groups. Treatment-emergent extrapyramidal symptoms were more numerous for risperidone- than placebo- or olanzapine-treated patients. Abnormally high prolactin levels occurred in 78.0% of risperidone patients, compared with 16.7% for olanzapine and 5.0% for placebo. The incidence of weight gain greater than 7% from baseline was higher in the olanzapine group relative to risperidone, but neither active-treatment group showed a statistical difference from placebo (1.1%). No other statistically significant and clinically relevant differences were seen for any other vital sign, electrocardiographic measure, or laboratory hematology and chemistry, including glucose, except for cholesterol, which decreased from baseline to endpoint in both active-treatment groups. Conclusions Patients' neuropsychiatric functioning improved with olanzapine, risperidone, and placebo treatment. There was a substantial response in the placebo group, and no significant differences emerged among treatments.
TL;DR: NPS were highly persistent overall, but many individuals became better or worse, and Clinically significant levels of NPS were associated with greater costs of care.
Abstract: Objectives Neuropsychiatric symptoms (NPS) are common in Alzheimer disease (AD) It is important in terms of management to know their natural history and their effects on service use The authors aimed to determine the persistence and change in severity of NPS over 6 months in participants with AD, and the relationship to initial severity, drug management, use of services, and cost of care Methods NPS scores and data on cognition, psychotropic medication, service use, and costs of care were collected on 224 participants at baseline and on 198 at 6-month follow-up Results Of 224 patients, 210 (938%) had NPS at baseline; 168 (750%) had at least one clinically significant symptom, 118 (804%) of whom had persistent significant symptoms at 6-month follow-up There was no significant change in mean NPS score for any symptom over 6 months, but many individuals became better or worse; 612% of those with at least one significant baseline symptom in any domain improved Those with persistent symptoms had more severe baseline symptoms Deterioration in NPS was predicted by deterioration in MMSE Those with at least one clinically significant symptom had higher care costs than those without Conclusions NPS were highly persistent overall, but many individuals became better or worse Persistence was predicted by having more severe symptoms at baseline Clinically significant levels of NPS were associated with greater costs of care The relatively few associations found between specific psychiatric treatments and changes in NPS reflect both undertreatment and the complexity of symptoms