Showing papers in "American Journal of Geriatric Psychiatry in 2011"
TL;DR: Although one or more apolipoprotein E ε 4 alleles and ever use of FDA-approved antidementia medications were associated with initial MMSE scores, neither was related to the rate of progression in any domain.
Abstract: Objectives Progression of Alzheimer dementia (AD) is highly variable. Most estimates derive from convenience samples from dementia clinics or research centers where there is substantial potential for survival bias and other distortions. In a population-based sample of incident AD cases, we examined progression of impairment in cognition, function, and neuropsychiatric symptoms, and the influence of selected variables on these domains. Design Longitudinal, prospective cohort study. Setting Cache County (Utah). Participants Three hundred twenty-eight persons with a diagnosis of possible/probable AD. Measurements Mini-Mental State Exam (MMSE), Clinical Dementia Rating sum-of-boxes (CDR-sb), and Neuropsychiatric Inventory (NPI). Results Over a mean follow-up of 3.80 (range: 0.07–12.90) years, the mean (SD) annual rates of change were −1.53 (2.69) scale points on the MMSE, 1.44 (1.82) on the CDR-sb, and 2.55 (5.37) on the NPI. Among surviving participants, 30% to 58% progressed less than 1 point per year on these measures, even 5 to 7 years after dementia onset. Rates of change were correlated between MMSE and CDR-sb (r = −0.62, df=201, p 2 = 8.7, df=2, p=0.013) and those with younger onset (likelihood ratio [LR] χ 2 = 5.7, df=2, p=0.058) declined faster on the MMSE. Although one or more apolipoprotein E η 4 alleles and ever use of FDA-approved antidementia medications were associated with initial MMSE scores, neither was related to the rate of progression in any domain. Conclusions A significant proportion of persons with AD progresses slowly. The results underscore differences between population-based versus clinic-based samples and suggest ongoing need to identify factors that may slow the progression of AD.
223 citations
TL;DR: The data suggest that women may have specific predisposition factors of multiple IS, which may involve both behavioral and hormonal factors, and Identification and treatment of these risk factors may form the basis of an intervention program for reduction of IS in the elderly.
Abstract: OBJECTIVES: the aim of this study was to examine the factors associated with insomnia in community-dwelling elderly as a function of the nature and number of insomnia symptoms (IS), e.g., difficulty with initiating sleep (DIS), difficulty with maintaining sleep (DMS), and early morning awakening (EMA). METHODS: is were assessed in a sample of 2,673 men and 3,213 women aged 65 years and older. The participants were administered standardized questionnaires regarding the frequency of IS and other sleep characteristics (snoring, nightmares, sleeping medication, and sleepiness) and various sociodemographic, behavioral and clinical variables, and measures of physical and mental health. RESULTS: more than 70% of men and women reported at least one IS, DMS being the most prevalent symptom in both men and women. Women reported more frequently two or three IS, whereas men reported more often only one IS. Multivariate regression analyses stratified by gender showed that men and women shared numerous factors associated with IS, sleeping medication, nightmares, sleepiness, chronic diseases, and depression being independently associated with two or three IS. For both sexes, age was associated with only one IS in all age categories. Loud snoring was strongly associated with increased DMS in men only. High body mass index increased the risk for DIS in men but tended to decrease it in women. In women, hormonal replacement therapy, Mediterranean diet, and caffeine and alcohol intake had a protective effect. CONCLUSION: our data suggest that women may have specific predisposition factors of multiple IS, which may involve both behavioral and hormonal factors. Identification and treatment of these risk factors may form the basis of an intervention program for reduction of IS in the elderly.
216 citations
TL;DR: Complementary use of a mind-body exercise, such as TCC, added to escitalopram may provide additional improvements of clinical outcomes in the pharmacologic treatment of geriatric depression.
Abstract: Background Nearly two-thirds of elderly patients treated for depression fail to achieve symptomatic remission and functional recovery with first-line pharmacotherapy. In this study, we ask whether a mind–body exercise, Tai Chi Chih (TCC), added to escitalopram will augment the treatment of geriatric depression designed to achieve symptomatic remission and improvements in health functioning and cognitive performance. Methods One hundred twelve older adults with major depression age 60 years and older were recruited and treated with escitalopram for approximately 4 weeks. Seventy-three partial responders to escitalopram continued to receive escitalopram daily and were randomly assigned to 10 weeks of adjunct use of either 1) TCC for 2 hours per week or 2) health education (HE) for 2 hours per week. All participants underwent evaluations of depression, anxiety, resilience, health-related quality of life, cognition, and inflammation at baseline and during 14-week follow-up. Results Subjects in the escitalopram and TCC condition were more likely to show greater reduction of depressive symptoms and to achieve a depression remission as compared with those receiving escitalopram and HE. Subjects in the escitalopram and TCC condition also showed significantly greater improvements in 36-Item Short Form Health Survey physical functioning and cognitive tests and a decline in the inflammatory marker, C-reactive protein, compared with the control group. Conclusion Complementary use of a mind–body exercise, such as TCC, may provide additional improvements of clinical outcomes in the pharmacologic treatment of geriatric depression.
178 citations
TL;DR: Neuroticism's association with late-life dementia mainly reflects vulnerability to stress and anxiety and their correlation with decline in the ability to process and retain new information.
Abstract: Objective To identify the components of the neuroticism trait most responsible for its association with cognitive decline and dementia in old age. Design Longitudinal clinical-pathologic cohort study. Setting Chicago metropolitan area. Participants A total of 785 older persons without dementia completed standard self-report measures of six components of neuroticism and then had annual clinical evaluations for a mean of 3.4 years and brain autopsy in the event of death. Measurements Incidence of clinically diagnosed Alzheimer disease (AD), change in global and specific cognitive functions, and postmortem measures of plaques and tangles, cerebral infarction, and Lewy bodies. Results During follow-up, 94 individuals developed AD. Higher levels of anxiety and vulnerability to stress were associated with increased risk of AD and more rapid decline in global cognition, with no effects for the other four trait components. In analyses of specific cognitive systems, neuroticism subscales were related to decline in episodic memory, working memory, and perceptual speed, but not in semantic memory or visuospatial ability. No component of neuroticism was related to the neuropathologic lesions most commonly associated with late-life dementia. Conclusions Neuroticism's association with late-life dementia mainly reflects vulnerability to stress and anxiety and their correlation with decline in the ability to process and retain new information.
165 citations
TL;DR: Three studies building on an increasingly robust body of evidence to guide development and implementation of interventions to reduce caregiver burden and its related costs are added to the American Journal of Geriatric Psychiatry.
Abstract: In 2005, Vitaliano et al.1 called in the American Journal of Geriatric Psychiatry for more caregiver research in geriatric psychiatry. Since 2005, caregiver outcomes have been addressed in more than 800 studies and reviews. This great outpouring of research reflects the perceived need for caregiver support that will inevitably accompany the vast increase in size of the older adult population in coming decades. As well, it reflects growing understanding of the complex determinants of adverse health outcomes of caregiver burden, and therefore the study of approaches to its mitigation.
This issue of the Journal adds three studies to this growing and increasingly sophisticated literature. One by Gaugler et al.2 highlights the important role that caregiver burden plays in mediating the oft-noted relationship between patient behavioral disturbance and nursing home admission. Two others report on results of multifaceted interventions tested in randomized controlled trials. Bakker et al.3 show that an intervention with multiple components assembled to meet the specific needs of an individual older adult and their caregiver resulted in caregiver assessments of significantly reduced neuropsychiatric symptoms and perceived burden. Examining implementation of care in a “real world” community context, Spijker et al.4 tested whether training of health professionals in the delivery of an intervention designed to support caregivers’ effectiveness reduced the need for institutional care. Revealing no significant impact, the findings provide helpful insights into the program and provider characteristics that may influence an intervention’s effectiveness, and which require additional study. Together, the studies build on an increasingly robust body of evidence to guide development and implementation of interventions to reduce caregiver burden and its related costs. We will attempt to place them in context by combining the Stress Process Model5 and the Appraisal Model6 into one heuristic conceptual framework (Figure 1). The models suggest that caregivers appraise caregiving events and then respond with particular behaviors. Emotional, psychological, and health outcomes follow these behaviors.
FIGURE 1
162 citations
TL;DR: A constricted life space is associated with increased risk of incident Alzheimer disease, mild cognitive impairment, and cognitive decline among older persons.
Abstract: Objective To test the hypothesis that a constricted life space, the extent of movement through the environment covered during daily functioning, is associated with increased risk of incident Alzheimer disease (AD), increased risk of mild cognitive impairment (MCI), and more rapid cognitive decline in older adults. Design Two prospective cohort studies. Setting Retirement communities, community-based organizations, churches, and senior subsidized housing facilities across the Chicago metropolitan area. Participants A total of 1,294 community-dwelling elders without baseline clinical dementia. Main Outcome Measures Detailed annual clinical evaluation to diagnose incident AD and MCI, and document change in cognitive function. Results During a mean (SD) follow-up of 4.4 (1.7) years, 180 persons developed AD. In a proportional hazards model controlling for age, sex, race, and education, a more constricted life space was associated with an increased risk of AD (hazard ratio=1.21, confidence interval: 1.08–1.36). A person with a life space constricted to their home was almost twice as likely to develop AD than a person with the largest life space (out of town). The association did not vary along demographic lines and persisted after the addition of terms for performance-based physical function, disability, depressive symptoms, social network size, vascular disease burden, and vascular risk factors. The association remained consistent after excluding persons with MCI at baseline and who developed AD in the first 2 years of observation. A constricted life space was also associated with an increased risk of MCI (hazard ratio=1.17, confidence interval: 1.06–1.28), and a more rapid rate of global cognitive decline (estimate: −0.012, standard error: 0.003, t [5033] = −3.58, p Conclusions A constricted life space is associated with increased risk of AD, MCI, and cognitive decline among older persons.
143 citations
TL;DR: Among ambulatory elders, cognition is associated with incident mobility impairment and mobility decline and Linear mixed-effects models showed that global cognition at baseline was associated with the rate of declining mobility.
Abstract: Objective To examine the association of cognitive function with the risk of incident mobility impairments and the rate of declining mobility in older adults. Design Prospective, observational cohort study. Setting Retirement communities across metropolitan Chicago. Participants A total of 1,154 ambulatory elders from two longitudinal studies without baseline clinical dementia or history of stroke or Parkinson disease. Measurements All participants underwent baseline cognitive testing and annual mobility examinations. Mobility impairments were based on annual timed walking performance. A composite mobility measure, which summarized gait and balance measures, was used to examine the annual rate of mobility change. Results During follow-up of 4.5 years, 423 of 836 (50.6%) participants developed impaired mobility. In a proportional hazards model controlled for age, sex, education, and race, each 1-unit higher level of baseline global cognition was associated with a reduction to about half in the risk of mobility impairments (hazard ratio=0.51, 95% confidence interval: 0.40–0.66) and was similar to a participant being about 13 years younger at baseline. These results did not vary by sex or race and were unchanged in analyses controlling for body mass index, physical activity, vascular diseases, and risk factors. The level of cognition in five different cognitive abilities was also related to incident mobility impairment. Cognition showed similar associations with incident loss of the ability to ambulate. Linear mixed-effects models showed that global cognition at baseline was associated with the rate of declining mobility. Conclusions Among ambulatory elders, cognition is associated with incident mobility impairment and mobility decline.
123 citations
TL;DR: In dementia, the presence of depression corresponds to accelerated cognitive decline beyond gender and level of education, suggesting a unique influence of depression on the rate of cognitive decline in dementia.
Abstract: Objective There is evidence that major depression increases the risk for dementia, but there is conflicting evidence as to whether depression may accelerate cognitive decline in dementia. The authors tested the hypothesis that decline in cognitive function over time is more pronounced in patients with dementia with comorbid depression, when compared with patients with dementia without depression history. Design Prospective, longitudinal cohort study of aging. Setting Nursing home. Participants Three hundred thirteen elderly nursing home residents (mean age at baseline: 86.99 years, standard deviation=6.7; 83.1% women). At baseline, 192 residents were diagnosed with dementia, and another 27 developed dementia during follow-up. Thirty residents suffered from major depression at any point during the study, and 48 residents had a history of depression. Measurements The authors measured cognitive decline using change in Mini-Mental State Examination (MMSE) scores over up to 36 months. The authors calculated multilevel regression models to estimate the effects of age, gender, education, dementia status, depression, depression history, and an interaction between dementia and depression, on change in MMSE scores over time. Results Beyond the effects of age, gender, and education, residents showed steeper cognitive decline in the presence of dementia (β = −13.69, standard error=1.38) and depression (β = −4.16, SE=1.2), which was further accelerated by the presence of both depression and dementia (β = −2.72, SE=0.65). Conclusions In dementia, the presence of depression corresponds to accelerated cognitive decline beyond gender and level of education, suggesting a unique influence of depression on the rate of cognitive decline in dementia.
123 citations
TL;DR: The proportion of older adults going for substance abuse treatment for the first time is increasing relative to younger adults, and the pattern of drug use is also changing, with an increasing illicit drug involvement in older adult admissions.
Abstract: Objectives: To see whether the percentage of older adults entering substance abuse treatment for their first time was increasing and whether there were changes in the use patterns leading to the treatment episode, particularly an increase in illicit drugs. Setting: The Treatment Episode Data Sets publicly available from the Substance Abuse Mental Health Services Administration from 1998 to 2008. Participants: Young adults age 30–54 years as a comparison group (N = 3,547,733) and those age 55 years or older (N = 258,542) with a first-time admission for a publicly funded substance abuse treatment. Measurements: Demographic and substance use history variables at admission. Result: The proportion of older adults going for substance abuse treatment for the first time is increasing relative to younger adults. The pattern of drug use is also changing, with an increasing illicit drug involvement (cocaine and heroin) in older adult admissions. Conclusions: We know little of these long-time users, their current medical state, cognitive abilities, and psychiatric symptoms after such a long exposure time. Previous studies on heroin and cocaine exposure focused on individuals identified much earlier in life, and the aging long-term users might represent a relatively large but unknown population.
117 citations
TL;DR: The authors found that hippocampal change from baseline to 2 years was associated with subsequent change in Mini-Mental State Examination score from 2 years to 2½ years and added to the literature linking hippocampal volume loss and late-life depression.
Abstract: Introduction Previous studies have linked hippocampal volume change and cognitive decline in older adults with dementia. The authors examined hippocampal volume change and cognitive change in older nondemented adults with and without major depression. Methods The sample consisted of 90 depressed individuals and 72 healthy, nondepressed individuals aged 60 years and older who completed at least 2 years of follow-up data. All patients underwent periodic clinical evaluation by a geriatric psychiatrist as well as baseline and 2-year magnetic resonance imaging. Results Over 2 years, the depressed group showed a greater reduction in left hippocampal volume (normalized for total cerebral volume) compared with the nondepressed group (mean difference = 0.013 ± 0.0059, t = 2.18, df = 160, p Conclusions These findings add to the literature linking hippocampal volume loss and late-life depression. Depressed patients with hippocampal volume loss are at greater risk of cognitive decline.
114 citations
TL;DR: SSRI treatment of GAD in older adults reduces HPA axis hyperactivity and genetic variability at the serotonin transporter promoter predicted cortisol changes, which were associated with improvements in anxiety.
Abstract: Background Generalized anxiety disorder (GAD) is a common disorder in older adults, which has been linked to hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis in this age group. The authors examined whether treatment of GAD in older adults with a selective serotonin reuptake inhibitor (SSRI) corrects this HPA axis hyperactivity. Methods The authors examined adults aged 60 years and older with GAD in a 12-week randomized controlled trial comparing the SSRI escitalopram with placebo. The authors collected salivary cortisol at six daily time points for 2 consecutive days to assess peak and total (area under the curve) cortisol, both at baseline and posttreatment. Results Compared with placebo-treated patients, SSRI-treated patients had a significantly greater reduction in both peak and total cortisol. This reduction in cortisol was limited to patients with elevated (above the median) baseline cortisol, in whom SSRI-treated patients showed substantially greater reduction in cortisol than did placebo-treated patients. Reductions in cortisol were associated with improvements in anxiety. Additionally, genetic variability at the serotonin transporter promoter predicted cortisol changes. Conclusions SSRI treatment of GAD in older adults reduces HPA axis hyperactivity. Further research should determine whether these treatment-attributable changes are sustained and beneficial.
TL;DR: This study demonstrates that clinically defined pre-MCI has cognitive, functional, motor, behavioral and imaging features that are intermediate between NCI and MCI states at baseline.
Abstract: Objective To compare clinical, imaging, and neuropsychological characteristics and longitudinal course of subjects with pre-mild cognitive impairment (pre-MCI), who exhibit features of MCI on clinical examination but lack impairment on neuropsychological examination, to subjects with no cognitive impairment (NCI), nonamnestic MCI (naMCI), amnestic MCI (aMCI), and mild dementia. Methods For 369 subjects, clinical dementia rating sum of boxes (CDR-SB), ApoE genotyping, cardiovascular risk factors, parkinsonism (UPDRS) scores, structural brain MRIs, and neuropsychological testing were obtained at baseline, whereas 275 of these subjects received an annual follow-up for 2–3 years. Results At baseline, pre-MCI subjects showed impairment on tests of executive function and language, higher apathy scores, and lower left hippocampal volumes (HPCV) in comparison to NCI subjects. Pre-MCI subjects showed less impairment on at least one memory measure, CDR-SB and UPDRS scores, in comparison to naMCI, aMCI and mild dementia subjects. Follow-up over 2–3 years showed 28.6% of pre-MCI subjects, but less than 5% of NCI subjects progressed to MCI or dementia. Progression rates to dementia were equivalent between naMCI (22.2%) and aMCI (34.5%) groups, but greater than for the pre-MCI group (2.4%). Progression to dementia was best predicted by the CDR-SB, a list learning and executive function test. Conclusion This study demonstrates that clinically defined pre-MCI has cognitive, functional, motor, behavioral and imaging features that are intermediate between NCI and MCI states at baseline. Pre-MCI subjects showed accelerated rates of progression to MCI as compared to NCI subjects, but slower rates of progression to dementia than MCI subjects.
TL;DR: A range of critical problems facing the vascular depression hypothesis are highlighted and the effort to establish the illness as a unique diagnostic entity in late-life is established.
Abstract: Since being proposed as a unique subtype of late-life depression (LLD), the vascular depression hypothesis has received considerable research attention. Although this effort has generated considerable empirical support for the validity of the subtype, fundamental questions remain including how the illness is defined, whether cerebrovascular disease and executive dysfunction (ED) define two separate entities or one underlying subtype, and whether ED is responsible for poor response to antidepressant treatment. In this guest editorial, we explore these and other issues (i.e., the role of personality and social support, psychosocial treatments targeting cognitive abilities frequently impaired in LLD) using a number of important papers that are either directly or indirectly related to the vascular depression hypothesis. In so doing we highlight a range of critical problems facing the vascular depression hypothesis and the effort to establish the illness as a unique diagnostic entity in late-life.
TL;DR: The N.T Neurocognitive Disorders (NCDs) Work Group of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Task Force began work in April 2008 on their task of proposing revisions to the criteria for the disorders referred to in DSM-IV as Delirium, Dementia, Amnestic, and Other Cognitive Disorders.
Abstract: T Neurocognitive Disorders (NCDs) Work Group of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Task Force began work in April 2008 on their task of proposing revisions to the criteria for the disorders referred to in DSM-IV as Delirium, Dementia, Amnestic, and Other Cognitive Disorders.1 Over the past 2 years, we have, among ourselves and with input from outside consultants and advisors, worked to develop a draft that was posted on the APA’s Web site www.dsm5.org in February 2010. This draft contained both an overview/rationale for the approach we have taken to date and preliminary criteria for the broadly defined disorders. Without reiterating here all the material posted on the Web site, we will provide our approach to the challenges we faced and some rationale for that approach. We are also pleased to have this opportunity to respond publicly both to the many comments directed to the Work Group on and off the Web site, and to the very thoughtful and constructive commentary provided by Drs. Rabins and Lyketsos in this issue.2 Finally, while this response is directed to the readership of the American Journal of Geriatric Psychiatry, we emphasize that the
TL;DR: Continuing treatment with antidepressants in elderly patients is efficacious compared with placebo in preventing relapses and recurrences and Efficacy and tolerability during long-term treatment does not differ between TCAs and SSRIs.
Abstract: Objective To establish the efficacy and tolerability of continuing treatment with antidepressants in preventing relapses and recurrences in elderly depressed patients and to analyze differences between tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs). Design The authors conducted a systematic literature search to identify all randomized, placebo-controlled, double-blinded clinical trials (RCTs) in elderly patients. Data were pooled from eight double-blinded RCTs of continuation and maintenance treatment in the elderly with 925 participating patients. Results The number of patients needed to treat (NNT) for antidepressants to prevent one additional relapse or recurrence was 3 6 (95% confidence interval [CI]: 2.8–4.8). The NNT for TCAs was 2.9 (95% CI: 2.2–4.6), compared with a NNT for SSRIs of 4.2 (95% CI: 3.2–5.9). In the five studies that provide drop out data, 14 of 330 patients (4.2%) using an antidepressant dropped out due to side effects compared with 17 of 330 patients (5.2%) using a placebo (x 2 = 0.305, df=1, p=0.581). Tolerability did not differ between TCAs and SSRIs. Conclusion Continuing treatment with anti-depressants in elderly patients is efficacious compared with placebo in preventing relapses and recurrences. Efficacy and tolerability during long-term treatment does not differ between TCAs and SSRIs. (Am J Geriatr Psychiatry 2011; 19:249–255)
TL;DR: Although these results need to be replicated in larger samples, the loss of short-term practice effects portends a worse prognosis in patients with aMCI.
Abstract: Objective Practice effects on cognitive tests have been shown to further characterize patients with amnestic mild cognitive impairment (aMCI) and may provide predictive information about cognitive change across time. We tested the hypothesis that a loss of practice effects would portend a worse prognosis in aMCI. Design Longitudinal, observational design following participants across 1 year. Setting Community-based cohort. Participants Three groups of older adults: 1) cognitively intact (n = 57), 2) aMCI with large practice effects across 1 week (MCI + PE, n=25), and 3) aMCI with minimal practice effects across 1 week (MCI − PE, n=26). Measurements Neuropsychological tests. Results After controlling for age and baseline cognitive differences, the MCI − PE group performed significantly worse than the other groups after 1 year on measures of immediate memory, delayed memory, language, and overall cognition. Conclusions Although these results need to be replicated in larger samples, the loss of short-term practice effects portends a worse prognosis in patients with aMCI.
TL;DR: Heavy caregiver burden is associated with mortality and hospitalization among community-dwelling dependent older adults, even after adjusting for potential confounders.
Abstract: Objective To determine whether caregiver burden is associated with subsequent all-cause mortality or hospitalization among dependent community-dwelling older care recipients. Methods A prospective cohort study of 1,067 pairs of community-dwelling 65-year-old or older care recipients and their informal caregivers was conducted. The 1,067 pairs completed the baseline assessment including caregiver burden assessed by the Zarit Burden Interview and a 3-year follow-up for all-cause mortality and hospitalization. Results During the 3-year follow-up, 268 recipients died and 455 were admitted to hospitals. The multivariate Cox proportional hazards model revealed that the recipients with caregivers with a baseline ZBI score in the highest quartile were 1.54 and 1.51 times more likely to show increased risks of all-cause mortality and hospitalization, respectively, in comparison with those with caregivers in the lowest quartile after adjustment for potential confounders. The highest quartile of caregiver burden was associated with all-cause mortality and hospitalization within nonusers of respite services including day-care services, home-help services, and nursing-home respite stay services. No apparent association was observed within the users of these services except for day-care services, for which users showed a statistically significant association between the highest quartile and the risk of hospitalization. Conclusions Heavy caregiver burden is associated with mortality and hospitalization among community-dwelling dependent older adults, even after adjusting for potential confounders. The reduction of caregiver burden and improvement of caregiver well-being may not only prevent the deterioration of caregiver health but also reduce adverse health outcomes for care recipients.
TL;DR: Patients treated with antidepressants had better recovery from disability by 1-year post stroke (i.e., 9 months after antidepressants were stopped) than patients who did not receive antidepressant therapy, suggesting that antidepressants may facilitate the neural mechanisms of recovery in patients with stroke.
Abstract: Objective Stroke often produces marked physical and cognitive impairments leading to functional dependence, caregiver burden, and poor quality of life. We examined the course of disability during a 1-year follow-up period after stroke among patients who were administered antidepressants for 3 months compared to patients given placebo for 3 months. Methods A total of 83 patients entered a double-blind randomized study of the efficacy of antidepressants to treat depressive disorders and reduce disability after stroke. Patients were assigned to either fluoxetine (N = 32), nortriptyline (N = 22) or placebo (N = 29). Psychiatric assessment included administration of the Present State Examination modified to identify DSM-IV symptoms of depression. The severity of depression was measured using the 17-item Hamilton Depression Rating Scale. The modified Rankin Scale was used to evaluate the disability of patients at initial evaluation and at quarterly follow-up visits for 1 year. Impairment in activities of daily living was assessed by Functional Independence Measure at the same time. Results During the 1-year follow-up period, and after adjusting for critical confounders including age, intensity of rehabilitation therapy, baseline stroke severity, and baseline Hamilton Depression Rating Scale, patients who received fluoxetine or nortriptyline had significantly greater improvement in modified Rankin Scale scores compared to patients who received placebo ( t [156] = −3.17, p=0.002). Conclusions Patients treated with antidepressants had better recovery from disability by 1-year post stroke (i.e., 9 months after antidepressants were stopped) than patients who did not receive antidepressant therapy. This effect was independent of depression suggesting that antidepressants may facilitate the neural mechanisms of recovery in patients with stroke.
TL;DR: Exercise may affect not only risk for AD but also subsequent disease duration: more PA is associated with prolonged survival in AD.
Abstract: Objectives To examine the association between physical activity (PA) and Alzheimer disease (AD) course. Background PA has been related to lower risk for AD. Whether PA is associated with subsequent AD course has not been investigated. Methods In a population-based study of individuals aged 65 years and older in New York who were prospectively followed up with standard neurologic and neuropsychological evaluations (every ∼1.5 years), 357 participants i) were nondemented at baseline and ii) were diagnosed with AD during follow-up (incident AD). PA (sum of participation in a variety of physical activities, weighted by the type of activity [light, moderate, and severe]) obtained 2.4 (standard deviation [SD], 1.9) years before incidence was the main predictor of mortality in Cox models and of cognitive decline in generalized estimating equation models that were adjusted for age, gender, ethnicity, education, comorbidities, and duration between PA evaluation and dementia onset. Results One hundred fifty incident AD cases (54%) died during the course of 5.2 (SD, 4.4) years of follow-up. When compared with incident AD cases who were physically inactive, those with some PA had lower mortality risk, whereas incident AD participants with much PA had an even lower risk. Additional adjustments for apolipoprotein genotype, smoking, comorbidity index, and cognitive performance did not change the associations. PA did not affect rates of cognitive or functional decline. Conclusion Exercise may affect not only risk for AD but also subsequent disease duration: more PA is associated with prolonged survival in AD.
TL;DR: CT may be a viable secondary prevention technique for late-life depression, a group who are at risk of further cognitive decline and progression to dementia.
Abstract: Objective To evaluate the efficacy of a multifactorial cognitive training (CT) program for older people with a lifetime history of depressive disorder. Methods This was a single-blinded waitlist control design. The study was conducted in the Healthy Brain Ageing Clinic, a specialist outpatient clinic at the Brain & Mind Research Institute, Sydney, Australia. Forty-one participants (mean age=64.8 years, sd=8.5) with a lifetime history of major depression were included. They were stabilized on medication and had depressive symptoms in the normal to mild range. The intervention encompassed both psychoeducation and CT. Each component was 1-hour in duration and was delivered in a group format over a 10-week period. Psychoeducation was multifactorial, was delivered by health professionals and targeted cognitive strategies, as well depression, anxiety, sleep, vascular risk factors, diet and exercise. CT was computer-based and was conducted by Clinical Neuropsychologists. Baseline and follow-up neuropsychological assessments were conducted by Psychologists who were blinded to group allocation. The primary outcome was memory whilst secondary outcomes included other aspects of cognition and disability. Results CT was associated with significant improvements in visual and verbal memory corresponding to medium to large effect sizes. Conclusion CT may be a viable secondary prevention technique for late-life depression, a group who are at risk of further cognitive decline and progression to dementia. (Am J Geriatr Psychiatry 2011; 19:240–248)
TL;DR: Both symptom and clinical significance criteria do not perfectly discriminate between older adults with or without a severe anxiety problem presenting comorbid disorders and needing psychiatric help.
Abstract: Anxiety disorders fulfilling DSM-IV criteria are common in community-dwelling older adults with prevalence estimates hovering between 0.1% and 15%, depending on the time period considered.1–5 Studies suggest that late-life sub-threshold anxiety is even more prevalent6–8 and could significantly interfere with functioning as much as disorders meeting full DSM criteria.9–11 Subthreshold anxiety usually refers to a condition where individuals do not meet the full symptom criteria (i.e., the number of symptoms required for a formal diagnosis is not reached) and/or do not report significant impairment or distress in functioning (i.e., the clinical significance criterion is not met).6–8 Despite its relevance in older adults, manifestations of subthreshold anxiety are nevertheless not considered as disorders according to the DSM-IV, particularly when the clinical significance criterion is not met. The rationale behind the introduction of the clinical significance criterion was to help identify a group of people presenting a more severe condition needing psychiatric help.12 One of the major problems with this criterion is that no operational definition exists for measuring impairment or distress.13 The evidence for impairment is often not clear-cut; clinicians have to rely on their own judgment to determine whether reported symptoms significantly interfere with daily functioning. Studies with younger adults suggest that the inclusion of the clinical significance criterion substantially decreases the prevalence rate of anxiety disorders by minimizing false positive (i.e., instances in which individuals who do not have a given psychiatric disorder are mistakenly diagnosed as having the disorder) and negative cases (i.e., instances in which individuals with a given psychiatric disorder are mistakenly diagnosed as not having the disorder).12–14 However, the use of this criterion with older adults may conversely increase the number of false-negative cases, since they are usually less active and less likely to perceive themselves as disabled than younger adults.15 In addition, because older adults are more likely to somatize their distress and to report less emotional disturbances,8,16–18 the symptom criteria may be harder to satisfy in this population.
Knowing that the symptom and the clinical significance criteria may pose problems in the older adult population, the aim of the current study was to answer the following questions: (a) how these criteria affect the prevalence estimates of anxiety problems in this population and (b) do these criteria identify a group of older adults presenting a more severe condition needing psychiatric help? To answer these questions, respondents with a full anxiety disorder were compared with respondents presenting different patterns of subthreshold anxiety on their sociodemographic, health, and health behavior characteristics. Since respondents’ health and health behavior characteristics were chosen on the basis of their potential association with the severity of anxiety,19–22 they should distinguish older adults having a more severe condition, as a full anxiety disorder, from respondents with subthreshold anxiety as well as distinguishing older adults reporting subthreshold anxiety from others without symptoms of anxiety.
TL;DR: The risk of dementia was high for current users and decreased as the duration of BZD discontinuation lengthened, and further investigations are needed to replicate this association and explore the underlying mechanism that links long-term BzD use, BZd discontinuation, and the pathogenesis of neurocognitive dysfunction.
Abstract: Objectives This study aimed to examine whether benzodiazepine (BZD) discontinuation would decrease the risk of dementia. Design A population-based nested case-control study of dementia was used. Setting All subjects aged 45 years or older and enrolled in the National Health Insurance Research Database in Taiwan between 1997 and 2007 were randomly selected. Participants A total of 8,434 cases had been identified with dementia at least three times in ambulatory claims or with one record in inpatient claims. They were individually matched with two comparison subjects (N = 16,706) by age, gender, and index date. Measurements The lengths of discontinuation, cumulative BZD dose, and potential confounding factors, including medical and psychiatric disorders, were measured and used for further analysis. Results Compared with nonusers, current users had an increased risk of dementia (adjusted odds ratio [aOR] = 2.71; 95% confidence interval [CI], 2.46-2.99). The dementia risk for former users was reduced as the duration of discontinuation lengthened ( 3 years aOR = 1.08, 95% CI, 0.98-1.20). The decreasing trend was significant (p Conclusion The risk of dementia was high for current users and decreased as the duration of BZD discontinuation lengthened. Further investigations are needed to replicate this association and explore the underlying mechanism that links long-term BZD use, BZD discontinuation, and the pathogenesis of neurocognitive dysfunction.
TL;DR: Psychosocial group intervention improved lonely older people's cognition by enhancing interaction and friendships between participants and to socially stimulate them.
Abstract: Objective: Loneliness may predict impaired cognition among older people. The aim of this study was to determine the effects of socially stimulating group intervention on cognition among older individuals suffering from loneliness. Design: A randomized controlled trial. Setting and Participants: Two hundred thirty-five participants (≥75 years) in seven day care centers in Finland. Intervention: Group intervention was based on the effects of closed-group dynamics and peer support. The three-month intervention was aimed to enhance interaction and friendships between participants and to socially stimulate them. Each group was facilitated by two specifically trained professionals. In addition to active discussions, the groups included three types of activities depending on the participants' interests: 1) therapeutic writing; 2) group exercise; and 3) art experiences. Measurements: Cognition was measured by the Alzheimer's Disease Assessment Scale (ADAS–Cog), and mental function was measured by the 15D measure. Results: The intervention and control groups were similar at baseline with respect to their demographics, disease burden, depression, and cognition. The ADAS–Cog scale improved more in the intervention group than in the control group within the three-month period, with mean changes being −2.6 points (95% confidence interval [CI]: −3.4 to −1.8) and −1.6 points (95% CI: −2.2 to −1.0), respectively. The dimension of mental function in the 15D showed significant improvement at 12 months in the intervention group (+0.048, 95% CI: +0.013 to +0.085) compared with the control group (−0.027, 95% CI: −0.063 to +0.010). Conclusion: Psychosocial group intervention improved lonely older people's cognition.
TL;DR: A stepped-care approach to the prevention of depression and anxiety in late life was not only successful in halving the incidence of depressive and anxiety disorders after 1 year, but these favorable effects were also sustained over 24 months.
Abstract: Objective Depressive and anxiety disorders in later life have a high incidence and are associated with reduced quality of life. Elsewhere, we demonstrated that a stepped-care prevention approach was successful in halving the incidence of these disorders over a period of 12 months. As a decreasing effect over time is to be expected, our aim was to investigate the longer-term effects. Design Randomized controlled trial. Setting Thirty-three primary care practices in the Netherlands. Participants One hundred seventy consenting individuals, age 75 years and older, presenting with subthreshold depression or anxiety, not meeting the diagnostic criteria. Intervention Participants were randomized to a preventive intervention or usual care. In the first 12 months, the preventive intervention entailed watchful waiting, minimally supported CBT-based self-help intervention, problem-solving treatment, and referral to a primary care physician for medication, if required. In the last 12 months, 95% of the participants ceased to receive such support. Measurements Mini International Neuropsychiatric Interview. Results The cumulative incidence rate of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, major depression or anxiety disorder over a period of 24 months was halved by the intervention, from 33 of 84 (39.3%) in the usual care group to 17 of 86 (19.8%) in the intervention group (odds ratio=0.38; 95% confidence interval=0.19–0.76), which was significant (z = 2.75; p=0.006). The corresponding number needed to treat was 5 (95% confidence interval=3–16). Conclusions A stepped-care approach to the prevention of depression and anxiety in late life was not only successful in halving the incidence of depressive and anxiety disorders after 1 year, but these favorable effects were also sustained over 24 months. (Am J Geriatr Psychiatry 2011; 19:230–239)
TL;DR: Considering that late-life GAD is associated with impaired quality of life but low levels of professional help-seeking increased effort is needed to help individuals with this disorder to access effective treatments.
Abstract: Objectives The objectives of this study are to provide current estimates of the prevalence and correlates of generalized anxiety disorder (GAD). Methods The authors used Wave 2 data from the National Epidemiologic Survey on Alcohol and Related Conditions, which included 12,312 adults 55+ and older. In addition to examining the prevalence of GAD in the past year, this study explored psychiatric and medical comorbidity, health-related quality of life, and rates of help–seeking and self-medication. Results The past-year prevalence of GAD in this sample was 2.80%, although only 0.53% had GAD without Axis I or II comorbidity. The majority of individuals with GAD had mood or other anxiety disorders, and approximately one quarter had a personality disorder. Individuals with GAD were also more likely to have various chronic health problems although these associations disappeared after controlling for psychiatric comorbidity. Health-related quality of life was reduced among older adults with GAD, even after controlling for health conditions and comorbid major depression. Finally, only 18% of those without and 28.3% with comorbid Axis I disorders sought professional help for GAD in the past year. Self-medication for symptom relief was rare (7.2%). Conclusions GAD is a common and disabling disorder in later life that is highly comorbid with mood, anxiety, and personality disorders; psychiatric comorbidity is associated with an increased risk of medical conditions in this population. Considering that late-life GAD is associated with impaired quality of life but low levels of professional help-seeking increased effort is needed to help individuals with this disorder to access effective treatments.
TL;DR: Minority groups in Philadelphia, especially Latinos, exhibit a more severe profile of AD at the time of presentation than WNHs and future research comparing immigrant and nonimmigrant Latino groups will be necessary to elucidate the highly significant differences reported.
Abstract: Objective To compare presentation of Alzheimer disease (AD) at the time of initial evaluation at a university specialty clinic across three ethnoracial groups in order to understand similarities and differences in the demographic, clinical, cognitive, psychiatric, and biologic features. Design Cross-sectional study. Participants A total of 1,341 self-identified African American, Latino (primarily of Caribbean origin), and white non-Hispanic ("WNH") subjects were recruited from primary care sites or by referral by primary care physicians. Measurements Demographic variables and age of onset of AD, as well as cognitive, functional, and mood impairments at the time of initial presentation and frequencies of apolipoprotein E genotypes, were compared across groups. Results Differences among ethnoracial groups were found for nearly all variables of interest. In particular, the largely immigrant Puerto Rican Latino group had an earlier age of onset of AD, more cognitive impairment, and greater severity of cognitive impairment at the time of initial evaluation in the setting of low average education and socioeconomic status. There was more depression in the Latinos compared with African Americans and WNHs. Greater severity of symptoms was not accounted for by a difference in lag time between onset of symptoms and initial evaluation. The apolipoprotein E-4 genotype was not associated with AD in the Latino cohort. Conclusions Minority groups in Philadelphia, especially Latinos, exhibit a more severe profile of AD at the time of presentation than WNHs. Important potential confounds need to be considered and future research comparing immigrant and nonimmigrant Latino groups will be necessary to elucidate the highly significant differences reported.
TL;DR: Late-life depression is associated with a higher risk of mortality, and physical inactivity and physical dysfunction might partly mediate this association, although further longitudinal studies are required to fully elucidate these mechanisms.
Abstract: Objective: The authors used an objective assessment of physical function and a range of sociodemographic, dietary, and health behaviors to explore the possible factors that could explain the association between depression and mortality in community-dwelling elderly participants aged 65 years and older. Design: Prospective follow-up of the National Diet and Nutrition Survey in older adults. Setting: Community sample. Participants: A total of 1,007 participants (522 men, 485 women; mean age: 76.4 +/- 7.3 years). Measurements: Depression was assessed from the 15 item Geriatric Depression Scale (GDS) and physical function using hand grip strength. Participants were followed up for death over an average of 9.2 years. Results: At baseline, 20.9% of participants demonstrated depression (GDS-15 score >= 5). Depressed participants were at a higher relative risk of all cause mortality during follow-up (age-and sex-adjusted hazard ratio = 1.24, 95% confidence interval: 1.04-1.49). Other risk factors for depression also related to mortality included smoking, physical inactivity, and low grip strength. These factors collectively explained an estimated 54% of the association between depression and mortality. Low-grade inflammation and low plasma vitamin C were also independently associated with depression and mortality but did not explain any of the association between depression and mortality. Conclusion: Late-life depression is associated with a higher risk of mortality. Physical inactivity and physical dysfunction might partly mediate this association, although further longitudinal studies are required to fully elucidate these mechanisms. (Am J Geriatr Psychiatry 2010; 19:72-78)
TL;DR: The findings suggest that it may increase the odds of depression in older men and suggests the need for careful planning of retail in residential environments, particularly near housing for older adults.
Abstract: Objective This study examined the impact of built environment (BE) attributes on depression in older men to determine whether associations were independent of neighborhood composition factors and sociodemographic, psychosocial, and health factors at the individual level. Methods The authors used geocoded data from the Health in Men Study collected in Western Australia in 2001 (N = 5,218). Depression was measured using the self-rated 15-item Geriatric Depression Scale. Geographic Information Systems were used to objectively measure BE attributes. Univariate logistic regressions were applied to select relevant covariates. Multivariate logistic regressions were conducted to examine BE attributes both separately and conjointly. Results Higher degrees of land-use mix were associated with higher odds of depression independent of other factors, including street connectivity and residential density (odds ratio=1.54, 95% confidence interval [CI] = 1.10–2.16, and odds ratio=1.52, 95% CI=1.08–2.14 for the second and third tertiles, respectively). Further examination showed that retail availability was associated with a 40% increase in the odds of depression (95% CI=4%–90%) independent of other factors, including availability of other land uses. Conclusions The BE is independently associated with depression through land-use mix, and specifically through retail availability. Although local retail facilitates walking, our findings suggest that it may increase the odds of depression in older men. This requires further exploration but suggests the need for careful planning of retail in residential environments, particularly near housing for older adults.
TL;DR: The results show that poor sleep quality and greater severity of SAS were associated with impaired language function reflecting frontal-subcortical pathology in patients with MCI, suggesting that vulnerability to a specific brain damage associated with SAS could increase the risk for dementia.
Abstract: Objectives Sleep apnea syndrome (SAS) is considered a risk factor for cognitive decline in the elderly. The specific neurocognitive decline has been suggested as a predictive factor for dementia in patients with mild cognitive impairment (MCI). The authors aim to illustrate the sleep characteristics related to the specific neurocognitive decline in the community-dwelling elderly including patients with MCI. Design Cross-sectional. Settings Center for sleep and chronobiology in Kangwon National University Hospital. Participants Thirty patients with MCI and 30 age- and sex-matched normal elderly subjects were selected. Measurements The authors administered seven tests in the Korean version of the Consortium to Establish A Registry of Alzheimer's Disease Neuropsychological battery and conducted nocturnal polysomnography. A p value below 0.05 was considered a statistical significance. Results There was no significant difference in sleep parameters between the MCI and normal comparison (NC) groups. Sleep efficiency was positively correlated with Constructional Recall (CR) scores in both NC and MCI groups (r = 0.393 and 0.391, respectively). The amount of slow wave sleep (SWS) was also positively correlated with Boston naming test (BNT) scores in both groups (r = 0.392, 0.470, respectively). Stepwise multiple regression models showed that SWS and the apnea index were significant independent variables associated with the BNT score (Δβ = 0.43 and −0.34, respectively; adjusted R 2 = 0.298) in the MCI group, and the amount of rapid eye movement sleep was a significant independent variable associated with the CR score (Δβ = 0.49; adjusted R 2 = 0.217) in the NC group. Conclusions Our results show that poor sleep quality and greater severity of SAS were associated with impaired language function reflecting frontal-subcortical pathology in patients with MCI. This suggests that vulnerability to a specific brain damage associated with SAS could increase the risk for dementia.
TL;DR: Preliminary evidence of a neuroprotective role of the val/val genotype is provided, suggesting that neurotrophic factor production protects against pathophysiological processes triggered by depression in older adults with later age of onset of MDD.
Abstract: Objectives Structural abnormalities in the hippocampus have been implicated in the pathophysiology of major depressive disorder (MDD). The brain-derived neurotrophic factor ( BDNF ) val66met polymorphism may contribute to these abnormalities and therefore confer vulnerability to MDD. This study examined whether there is a relationship among BDNF genotype, hippocampal volumes, and MDD in older adults. Methods Thirty-three older adults with MDD and 23 psychiatrically normal comparison subjects were studied. Structural magnetic resonance imaging analysis was used to quantify hippocampal volumes. A repeated-measures analysis of covariance examined the relationships among BDNF val66met (val/val, met carrier), diagnosis (depressed, nondepressed), and hippocampal volumes (right, left). Age, gender, education, and whole brain volume were included as covariates. Results Elderly MDD BDNF val/val homozygotes had significantly higher right hippocampal volumes compared with nondepressed val/val subjects. However, there was no difference between the depressed and healthy nondepressed met carriers. In addition, depressed met carriers had an earlier age of onset of depressive illness than val/val homozygotes, but age of onset did not moderate the relationship between hippocampal volumes and MDD diagnosis. Conclusion These results provide preliminary evidence of a neuroprotective role of the val/val genotype, suggesting that neurotrophic factor production protects against pathophysiological processes triggered by depression in older adults with later age of onset of MDD. The BDNF val66met polymorphism may play a salient role in structural alterations of the hippocampus in older adults with MDD.