Alzheimer's disease, other dementias, depression and pseudodementia: prevalence, incidence and three-year outcome in Liverpool

Persistence of neuropsychologic deficits in the remitted state of late-life depression

OBJECTIVE

Cognitive impairment in late-life depression (LLD) is prevalent, disabling, and persists despite the remission of depressive symptoms. This article characterizes neuropsychologic functioning during remission in LLD.

METHODS

The authors examined longitudinal performance on a comprehensive neuropsychologic battery in 56 nondemented subjects age 60 or older who initially presented with an episode of nonpsychotic unipolar major depression and 40 nondemented, age- and education-equated comparison subjects with no history of depression. Subjects were assessed at baseline (in a depressed state) and one year later (when remitted).

RESULTS

After one year, 45% of the LLD subjects were cognitively impaired despite remission of depression. Visuospatial ability, information-processing speed, and delayed memory were most frequently impaired; 94% of the patients who were impaired at baseline remained impaired one year later. Twenty-three percent of the patients who were cognitively normal while depressed developed impairment one year later.

CONCLUSIONS

Most older individuals who are cognitively impaired during a depressive episode remain impaired when their depression remits. In addition, a substantial proportion of older depressed individuals who are cognitively intact when depressed are likely to be impaired one year later, although their depression has remitted.

The state of mental health in old-age across the 'old' European Union-- a systematic review

OBJECTIVE

The paper provides the first syllabus on the prevalence of mental disorders in old-age focusing on surveys conducted in the 15 countries, which comprised the 'old' European Union.

METHOD

A systematic search of the literature published from 1990 onwards was conducted.

RESULTS

Mental disorders in old-age are common. The most serious threats to mental health in old-age are posed by dementia and depression. It is a clear cut finding that dementia exponentially increases with age. The basic issue of whether depression increases or decreases with age remains unsolved. Databases on substance use, mild cognitive impairment, psychotic syndromes, anxiety, and somatoform disorders in old-age are much smaller, making conclusions difficult to draw.

CONCLUSION

Numerous questions in the field remain to be answered. Concerted action is needed to produce comparable data across Europe.

Three-year incidence of first-onset depressive syndrome in a population sample of older adults: the Cache County study

OBJECTIVE

Estimates of incidence of late-life depression vary greatly with few studies excluding demented cases through in-depth evaluation and most studies failing to control for the effect of mortality and interval treatment. In a large population-based study, the authors examined the effect on incidence of first-onset depressive syndrome to determine whether any gender or age differences in incidence are attenuated with inclusion of these additional measures.

METHOD

Incidence rates of depressive syndrome per 1,000 person-years are presented for 2,877 nondemented elderly (ages 65 to 100 years) residents of Cache County, Utah. Cases are identified by direct interview methods, by inference from prescription antidepressant medicine use, and by postmortem informant interview for decedents.

RESULTS

In-person interviews yielded incidence rates of first-onset depressive disorder (any type) of 13.09 for men and 19.44 for women. Inclusion of antidepressant users increased these figures to 15.55 for men and 23.30 for women. Addition of postmortem interview data yielded rates of 20.66 for men and 26.29 for women. Individuals with no history of depression had rates for major depression of 7.88 for men and 8.75 for women; minor depression rates were 19.23 for men and 24.46 for women (p = 0.691; effect for minor depression p <0.0001). Age did not predict incidence.

CONCLUSIONS

Incidence of first-onset major depression varies with data source and prior lifetime history of depression. Gender effects apparent in interview data are attenuated when postmortem information and pharmacotherapy were considered.

Cost of Alzheimer's disease in a developing country setting

PURPOSE

To evaluate the economic impact of AD in Denizli, Turkey.

DESIGN AND METHODS

This observational study was conducted with 42 AD patients and their primary caregivers. During the initial interview, demographic data and medical histories were collected with questionnaires. For an observational period of 15 days, data on time spent for patient care were collected using standard forms. Calculations on direct cost (e.g. per day medication, outpatient physician visits during the last 3 months), indirect cost (e.g. time spent for care by caregiver for daily living (ADL) and instrumental activity of daily living (IADL)) were made by summing up and taking averages of the appropriate items. ANOVA, and linear regressions were the methods for comparisons.

RESULTS

The primary caregivers of the patients mainly were their children and/or spouses. The maximum mean time spent (h/week) was 21.0 (17.5) for severely damaged cognition. The average annual cost per case was between $1,766 [95% Confidence Intervals (CI); 1.300-2.231] and $4,930 (95% CI; 3.3714-6.147). The amount of caregiver cost was the most significant item in the overall cost and it showed an increase with the declining cognitive function of patients. Daily medication cost reflected the same pattern. In contrast, cost of outpatient physician was the lowest among the patients with the worst cognition.

CONCLUSIONS

These results suggest that recently AD has become a significant cost for developing countries. This pilot study gives an idea of the cost of AD in developing countries where determining the actual cost can be difficult.

The Longitudinal Relationship Between the Use of Long-Term Care and Depressive Symptoms in Older Adults

PURPOSE

The aim of this study was to estimate the longitudinal relationship between transitions in the use of long-term care and older adults' depressive symptoms and to investigate whether this relationship could be explained by markers of older adults' underlying health, or other variables including demographics, personality, and partner status.

DESIGN AND METHODS

Data were from the Longitudinal Aging Study Amsterdam, which consists of a random, community-based sample of 3,107 older Dutch people (55-85 years of age) stratified by age and gender. The use of informal care, professional home care, and institutional care was recorded, and respondents were screened on depressive symptoms. Follow-up measurements took place at 3 and 6 years.

RESULTS

Longitudinal analyses showed significant associations between the enduring use of professional long-term care and an increase in depressive symptoms. Transitions to professional home care or institutional care were also associated with considerably more depressive symptoms after 3 years, whereas transitions from professional home care or institutional care to no care or informal care only were not associated with a change in depressive symptoms. Most of the associations remained significant after indicators of underlying health and other covariates were adjusted for, and also after the data were reanalyzed for respondents with and without functional limitations.

IMPLICATIONS

This study does not involve a controlled experiment of professional long-term care among older adults. However, the findings suggest the possibility that receiving professional long-term care could introduce new stressors and increase the risk of depressive symptoms. Our analyses illuminate the concerns of elders regarding their use of professional long-term care and may help in planning for more effective delivery of this type of care.

Epidemiology of late-life mental disorders

This article reviews the prevalence and incidence of mental disorders in older adults. The authors outline the epidemiologic challenges in determining the frequency of mental disorders in late-life and discuss issues that are critical for understanding the prevalence of the disorders and for reviewing the evidence from epidemiologic studies of mental disorders in this population. The authors summarize the epidemiologic data for depression, anxiety, dementia, schizophrenia, and alcoholism. Also included is a discussion of risk factors and outcomes of these disorders and a discussion of the implications of these epidemiologic findings for geriatric medicine.

Elderly patients with major depressive disorder and delusional disorder are at increased risk of subsequent dementia

All the patients (n=150) admitted to psychogeriatric clinic during a 1-year period were followed up until their death or for 10 years. Fifteen of these were lost during the 10-year follow-up. Thus, follow-up data were available for 135 patients. Twenty-four of these fulfilled at baseline the DSM-III-R diagnostic criteria of major depressive disorder and 18 of delusional disorder after careful medical examination and neuropsychological tests to eliminate organic causes. In the follow-up, the diagnoses were gathered from the death certificates of those patients who died during the 10-year period and all of the patients alive at the end of the study were interviewed to assess their mental state. Six out of the 24 (25%) patients with major depressive and five out of 18 (28%) patients with delusional disorder developed clear organic dementia before death or within 10 years (mean follow-up time 6.7 years). This is approximately double the expected incidence in the general population of that age. The gender, age at index admission, the baseline Mini Mental State Examination scores or findings in computer tomography did not contribute to the risk of dementia. Psychogeriatric patients admitted due to major mental disorder may have an increased risk of organic dementia in the near future.

APOE is associated with age-of-onset, but not cognitive functioning, in late-life depression

OBJECTIVE

There is a recognized but poorly understood relationship between late-life depression (LLD) and progressive dementia. Both cognitive impairment co-occurring with LLD and a late age-of-onset of first lifetime depressive episode appear to be associated with subsequent progressive dementia. A history of major depression, especially when the first onset occurs in late-life, has been identified as a risk factor for Alzheimer's disease (AD). The major genetic risk factor for sporadic AD is carrying one or more apolipoprotein E4 (APOE4) alleles. We hypothesized that the association between LLD and dementia risk would be mediated by APOE4, specifically that APOE4 allele frequency would be associated with cognitive impairment and later age-of-depression-onset. We also predicted that APOE4 allele frequency would be increased among subjects with LLD.

METHODS

We compared the distribution of APOE2, APOE3, and APOE4 alleles in groups of LLD (n=160), AD (n=568) and elderly control (EC; n=156) subjects.

RESULTS

The allele distribution of the cognitively impaired LLD subgroup was not different from either the cognitively normal subgroup or the EC group but was different from the AD group. However, mean age-of-onset of depression in APOE4 carriers (51.4+/-20.7) was significantly lower than non-carriers (58.8+/-16.8). The allele distribution in LLD overall was significantly different from the AD but not the EC group.

CONCLUSIONS

The finding that neither LLD, accompanying cognitive impairment, nor late age-of-onset was associated with an increased APOE4 allele frequency suggests that LLD acts as a risk factor for developing AD as well as non-AD dementia through mechanisms independent of APOE4. The unexpected finding that age-of-onset of LLD was significantly reduced in APOE4 carriers is similar to the association between APOE4 and age-of-onset in AD. Replication of the association of APOE4 with earlier age-of-depression-onset is indicated.

Comorbidity and risk-patterns of depression, generalised anxiety disorder and mixed anxiety-depression in later life: results from the AMSTEL study

BACKGROUND

Depression and generalised anxiety disorder frequently overlap. The question remains unresolved whether these are specific disorders, or that they represent different dimensions of a single disorder. Although both are highly prevalent disorders in this age group, studies on this issue in the elderly are scarce. Research is needed that investigates patterns of comorbidity and possibly different risk profiles for pure depression, pure generalised anxiety and mixed anxiety-depression in older people.

METHODS

GMS-AGECAT diagnoses were obtained from 4051 community living older persons. Comorbidity was studied along a severity gradient for men and women separately. Multivariate analysis of risk factors included demographic variables, environmental vulnerability, longstanding vulnerability, physical/functional stresses and gender.

RESULTS

The prevalence of pure depression was 12.2%, pure generalised anxiety 2.9%, mixed anxiety-depression 1.8%. Comorbidity increased with higher severity levels of both depression and generalised anxiety. Comorbidity was twice as likely in women than in men. Different risk profiles for diagnostic categories were not demonstrated for concurrent risk factors. Longstanding vulnerability was associated significantly stronger with mixed anxiety-depression than with pure anxiety and pure depression. Mixed anxiety-depression was overrepresented in women.

CONCLUSIONS

Both lines of investigation suggest that, in the elderly, a dimensional classification is more appropriate than a categorical classification of depression and generalised anxiety. Mixed anxiety-depression is a more severe form of psychopathology that is almost specific to women in this age group.

Dementia with Lewy bodies according to the consensus criteria in a general population aged 75 years or older

OBJECTIVE

To estimate the prevalence of dementia with Lewy bodies (DLB) according to the consensus criteria in a general population aged 75 years or older.

METHODS

The "Kuopio 75+ study" is a population based health survey focused on the clinical epidemiology of dementia and functional capacity among elderly subjects aged 75 years or older. On 1 January 1998, a random sample of 700 subjects was drawn from a total population born before 1 January 1923, living in the city of Kuopio, northeast Finland (n = 4518). The study subjects underwent a structured interview and clinical examination.

RESULTS

601 elderly subjects (86% of the random sample) were examined. A dementia disorder was diagnosed in 137-a prevalence of 22.8% (95% confidence interval 19.4% to 26.2%). The prevalence of DLB was 5.0% (3.2% to 6.7%), comprising 22% of all demented subjects. Probable DLB was diagnosed in 20 subjects (3.3% (1.9% to 4.8%)), and possible DLB in 10 (1.7% (0.6% to 2.7%)). The prevalence of Alzheimer's disease was 10.6% (47% of all demented subjects), of vascular dementia, 5.3% (23%), and of other types of dementing disorders, 1.8% (8%).

CONCLUSIONS

In a general population aged 75 years and older, the prevalence of a disorder fulfilling the diagnostic criteria of DLB is half that of Alzheimer's disease and the same as for vascular dementia.

Drug treatment in depressed elderly in the Dutch community

OBJECTIVES

In older people, a diagnosis of depression is frequently missed, and proper treatment is subsequently hampered. We investigated antidepressant and benzodiazepine use in an older community sample, and assessed possible risk factors associated with non-treatment in depressed elderly.

METHODS

Data were used from the baseline measurements of the Longitudinal Aging Study Amsterdam (LASA). In a random, age and sex stratified community sample of 3107 older Dutch people (55 to 85 years), respondents were screened on depression with the Center for Epidemiologic Studies Depression Scale (CES-D). In the depressed subsample depressive disorder according to DSM-III was assessed using the Diagnostic Interview Schedule (DIS). The use of antidepressants and anxiolytics (benzodiazepines) in the depressed subsample was measured, and associations with age, sex, cognitive impairment, physical health and anxiety symptoms were investigated.

RESULTS

Only 16% of the respondents with a major depressive disorder used antidepressants. More than half of them used non-therapeutic dosages. Lower antidepressant use was associated with cognitive impairment. Benzodiazepine use was more likely than antidepressant use, which was especially evident in females in the major depressive disorder group.

CONCLUSIONS

Depressed older people were undertreated, particularly when they were cognitively impaired. A high rate of benzodiazepine use was found, particularly in females.

A comparison of GMS-A/AGECAT, DSM-III-R for dementia and depression, including subthreshold depression (SD)--results from the Berlin Aging Study (BASE)

BACKGROUND

Empirical evaluation of the agreement between different diagnostic approaches is crucial for the understanding of epidemiological results in geriatric psychiatry.

OBJECTIVES

In this paper, we analyse differences between widely used diagnostic approaches of dementia and depression and offer evidence that diagnostic thresholds vary substantially on quantitative dimensions, but that conceptual and other differences between approaches must also been taken into account.

METHODS

In an epidemiological study of n = 516 persons, aged 70-103 years, we compared psychiatric diagnoses of dementia and depression obtained by GMS-A/HAS-AGECAT, DSM-III-R and clinician's diagnoses of subthreshold depression (SD).

RESULTS

For depression, cumulative prevalence of clinician's diagnosis (including SD, GMS-A/HAS-AGECAT and DSM-III-R defined forms) was highest, followed by GMS-A/HAS-AGECAT-diagnosis and DSM-III-R, while for dementia DSM-III-R was followed by GMS-A/HAS-AGECAT. Overall agreement between DSM-III-R and GMS-A/HAS-AGECAT was moderate. Adapting thresholds for AGECAT resulted in slightly better diagnostic efficiency. Diagnostic disagreement was found predominantly for cases with intermediate symptom severity, supporting the hypothesis of differing thresholds between DSM-III-R and GMS-A/HAS-AGECAT, while cases with lower or higher symptom severity were similarly seen as cases or non-cases.

CONCLUSION

Disagreement is not only caused by conceptual differences, but also different thresholds of diagnostic algorithms. Adaptation of threshold levels should be feasible, depending on the purpose of the analysis.

Accuracy of the 15-item geriatric depression scale (GDS-15) in a community sample of the oldest old

BACKGROUND

Cognitive impairment is common in the oldest old. This might influence the sensitivity and specificity of the 15-item Geriatric Depression Scale (GDS-15). Few studies, however, have included subjects older than 85 years to evaluate the GDS-15 as a screening instrument for depression.

OBJECTIVE

To assess the sensitivity and specificity of the GDS-15 in a community sample of the oldest old.

METHODS

Seventy-nine subjects aged 85 and over were enrolled in the study. The GDS-15 and the Mini-Mental State Examination (MMSE) were administered by a trained interviewer. Within two days the Geriatric Mental State (GMS)/AGECAT, was administered to obtain a clinical diagnosis of depression.

RESULTS

Eight subjects (10%) were diagnosed with clinical depression. At a cut-off point of 3/4 the sensitivity and specificity of the GDS-15 were 88% and 76% respectively. In the group with MMSE scores of 28 and higher sensitivity was unaffected at all cut-off points while specificity increased. In the group with MMSE scores below 28 sensitivity was also unaffected at all cut-off points while specificity decreased.

CONCLUSION

The GDS-15 is a suitable instrument to diagnose depression in the general population of the oldest old. The optimal cut-off point depends on its intended use. In subjects with cognitive impairment the accuracy should be investigated further.

Depression in subjects with and without dementia: a comparison using GMS-AGECAT

OBJECTIVE

To compare depression in subjects with and without dementia, adjusting for possible confounders.

BACKGROUND

The results of comparisons of depression between subjects with and without dementia are inconclusive. Probably confounders play a role.

METHODS

Ninety-one subjects with DSM-III-R dementia and 110 controls without dementia were recruited from homes for the elderly using an identical procedure. The prevalences of AGECAT depressive syndromes, subsyndromes and factors of depressive symptoms were compared adjusting for possible confounders.

RESULTS

(1) Both groups had similar prevalences of AGECAT depressive syndromes, subsyndromes and overall rates of depressive symptoms; (2) subjects with dementia had significantly more 'motivation symptoms'; and (3) there was a trend to a lower prevalence of 'mood symptoms' in subjects with dementia. These results refer to a sample of institutionalised elderly subjects. It is not clear to what extent they can be generalised to subjects living in the community.

CONCLUSION

The results indicate that it is not AGECAT (sub)syndrome measures of depression but the profile of depressive symptomatology which is affected by dementia.

The impact of depression on the well-being, disability and use of services in older adults: a longitudinal perspective

OBJECTIVE

To study the impact of depression on the wellbeing, disability and use of health services of older adults.

METHOD

Prospective community-based study, using a large (n = 2,200) sample of the elderly (55-85) in the Netherlands. Using a 3-year follow-up, the effect of depressive symptoms (CES-D) on disability, wellbeing and service utilization was assessed, controlling for competing need-for-care (chronic physical illness, functional limitation and cognitive decline), enabling (partner status, size of the social network, social support and locus of control), and predisposing factors (age, sex and level of education).

RESULTS

Depressive symptoms have considerable impact on the wellbeing and disability of older people and clear economic consequences caused by inappropriate service utilization. Compared with other need-for-care variables the impact of depression is weaker (service utilization), similar (disability) or stronger (wellbeing).

CONCLUSION

The steeply rising prevalence of competing health risks in later life does not influence the significance of depression.

The clock drawing test in primary care: sensitivity in dementia detection and specificity against normal and depressed elderly

OBJECTIVES

The aim of this study was to examine the sensitivities and specificities of the clock drawing test (CDT) in the detection of dementia among older people in primary care, with particular emphasis on the effect of depression on CDT specificity. Most previous studies have been sited in specialist settings and few have addressed the issue of specificity against depression.

METHODS

Comparison of cohorts identified from community-based screening with GMS-AGECAT. The CDT and the Mini-Mental State Examination (MMSE) were administered to 41 elderly subjects with organic disorder (dementia), 84 elderly subjects with case level depression and 523 normal elderly subjects. Sensitivities and specificities of the CDT were calculated.

RESULTS

The sensitivity of the CDT in the detection of dementia in the general community was 76%. The specificities of the CDT against normal elderly and depressed elderly was 81% and 77% respectively. Higher sensitivity and specificity were achieved by the MMSE.

CONCLUSIONS

The use of the CDT in the detection of dementia syndromes is likely to be more relevant in the primary care context than in specialist settings. The CDT provides good sensitivity and specificity but may not be as sensitive or specific in the general community as previous studies have suggested, particularly in mild dementia. Community-based late life depression does not appear to alter the specificity of the CDT.

Diagnosis of dementia from the history and aetiology schedule

OBJECTIVE

To provide a computerised method of diagnosing organic brain syndrome from history data without the use of mental state data.

METHODS

Interview dataset from participants in a community study of the incidence of dementia was used to form a training sample and validation sample. The algorithm was developed on the training sample and tested on the validation sample.

RESULTS

Performance in the training and validation samples was very similar. The algorithm shows monotonically increasing probability of being diagnosed with dementia as a function of the proposed level of diagnostic confidence. At the proposed cut point it has sensitivity 94% and specificity 84% for detecting concurrent psychiatrist's diagnosis of dementia.

CONCLUSIONS

The method provides a good agreement with psychiatrist's diagnosis, and the results in the validation sample show little shrinkage. The method will prove useful in studies where it has proved impossible to collect mental state information on all the study participants.

The incidence of dementia in an Australian community population: the Sydney Older Persons Study

OBJECTIVES

Limited Australian dementia incidence data are available. This study aimed to identify the incidence of dementia and its subtypes in an Australian community dwelling population.

METHOD

A community dwelling sample of 647 subjects aged > or =75 years at recruitment were followed for a mean period of 3.2 years (range 2.6-4.5 years). The incidence of dementia (measured in person years at risk) was identified for different levels of severity of dementia, Alzheimer's disease and vascular dementia.

RESULTS

Incidence figures were slightly higher than those previously reported. The incidence of dementia and of Alzheimer's disease increased with age but was not affected by gender. The incidence of vascular dementia was not affected by age.

CONCLUSION

This study provides the largest body of data on the incidence of dementia in Australia, indicating a slightly higher incidence of dementia than previous reports. Further Australian data are required to confirm these findings.

Emergence and persistence of late life depression: a 3-year follow-up of the Longitudinal Aging Study Amsterdam

BACKGROUND

The present study was designed to assess onset and persistence of late-life depression, systematically comparing the factors associated with prevalence, onset and prognosis.

METHODS

The data were derived from a large (n=2200), random, age and sex stratified sample of the elderly (55-85 years) in The Netherlands. Using a 3-year, prospective longitudinal design, both the onset and the persistence of depression were assessed. Depression was measured using the Center for Epidemiologic Studies Depression Scale. Risk factors associated with prevalence, onset and persistence were compared using both bivariate and multivariate analyses.

RESULTS

In those not depressed at index assessment, the onset of depression was 9.7%. Among those depressed at baseline, persistence occurred in 50.4%. Risk factors predicting onset were almost identical to those associated with prevalence. Persistence was predicted by very few factors (external locus of control and chronic physical illness).

CONCLUSIONS

The data suggest that cross-sectional studies are biased due to their overrepresenting chronic depressive episodes. However, the risk factors derived from cross-sectional studies do seem to adequately reflect factors associated with onset. The prognosis is not adequately predicted by variables usually included in epidemiological studies of late life depression. It is speculated that including more biological correlates of depression and data concerning positive life-changes may improve our understanding of the prognosis of late life depression.

Alzheimer's disease: insights from epidemiology

While a complete understanding of the pathogenesis of Alzheimer's disease (AD) remains elusive, many conclusions can be drawn from the numerous epidemiological studies undertaken to date. Prevalence and incidence estimates show consistency, following a roughly exponential pattern with a doubling of both parameters roughly every five years after age 65. Roughly 7% of the population aged 65 and over has AD. The clinical course of the disease is reasonably well established and mortality rates rise with increasing levels of cognitive deficit. Four risk factors for AD are firmly established: increasing age, the presence of the apolipoproteinE-epsilon4 allele, familial aggregation of cases, and Down's syndrome. Numerous other associations have been shown in some studies, but not in others. For example, women generally appear at higher risk than men, as do people with lower levels of education; depression is probably prodromal; head injury is an established risk factor, and may interact with the apoE gene; several occupational exposures appear hazardous, and exposure to aluminum in the water supply confers excess risk. Hypertension and other vascular symptoms appear to predispose to AD, which is now seen as nosologically closer to vascular dementia than was previously believed. Several apparently protective factors have been identified, although preventive trials based on these have so far shown minimal effectiveness. The use of non-steroidal anti-inflammatory drugs to treat arthritis is associated with a reduced risk of AD, as is estrogen use by post-menopausal women. Physical activity appears beneficial, as does a diet with high levels of vitamins B6, B12 and folate. while red wine in moderate quantities appears protective. This review concludes with a discussion of the strengths and limitations of current epidemiological methods for studying Alzheimer's disease.

Psychiatric disorder and personality factors associated with suicide in older people: a descriptive and case-control study

OBJECTIVE

To determine the rates of psychiatric disorder and personality variables in a sample of older people who had committed suicide and to compare the rates in a subgroup of this sample with those in a control group of people who died from natural causes.

DESIGN

Descriptive psychological autopsy study, including interviews with informants, of psychiatric and personality factors in 100 suicides in older people. Case-control study using subgroup of 54 cases and matched control group.

SETTING

Four counties and one large urban area in central England, UK.

SUBJECTS

Individuals 60 years old and over at the time of death who had died between 1 January 1995 and 1 May 1998, and whose deaths had received a coroner's verdict of suicide (or an open or accidental verdict, where the circumstances of death indicated probable suicide). The control group was an age-and sex-matched sample of people dying through natural causes in the same time period.

MAIN OUTCOME MEASURES

ICD-10 psychiatric disorder, personality disorder and trait accentuation.

MAIN RESULTS

Seventy-seven per cent of the suicide sample had a psychiatric disorder at the time of death, most often depression (63%). Personality disorder or personality trait accentuation was present in 44%, with anankastic or anxious traits the most frequent. Depression, personality disorder, and personality trait accentuation emerged as predictors of suicide in the case-control analysis.

CONCLUSION

Personality factors, as well as depression, are important risk factors for suicide in older people.

Depressive symptoms and risk of Alzheimer's disease in more highly educated older people

BACKGROUND AND OBJECTIVE

In an earlier study we observed that a depressive syndrome was highly predictive of developing Alzheimer's disease (AD) in older persons with normal baseline cognition and higher levels of education. We interpreted these findings as the depression being an early noncognitive manifestation of AD in persons with more cognitive reserve. The present study examines whether specific symptoms of depression can be identified that predict AD among older subjects with higher levels of education.

DESIGN AND PARTICIPANTS

In the community-based Amsterdam Study of the Elderly (AMSTEL), a sample of 3,147 nondemented persons with normal cognition, 65 to 84 years old, was selected and divided into subjects with >8 years and < or =8 years of education. At baseline, the presence or absence of 12 specific symptoms of depression was assessed. At follow-up, patients with incident AD were diagnosed according to DSM-IV criteria in a two-step diagnostic procedure.

RESULTS

After an average follow-up of 3.2 years, 1,911 persons were reevaluated, of whom 22 with > 8 years and 31 with < or =8 years of education had developed AD. Multivariate logistic regression analyses showed that among persons with >8 years of education depressed mood and subjective bradyphrenia were strongly associated with incident AD. No association between depressive symptoms and AD was observed among subjects with < or =8 years of education.

CONCLUSIONS

Both depressed mood and subjective bradyphrenia seem to indicate subclinical AD in older people with higher levels of education. Clinicians should be alert that in these persons, AD may become apparent within a relatively short period of time.

Risk factors for depression in later life; results of a prospective community based study (AMSTEL)

BACKGROUND

Depression in the elderly was found to be associated with a variety of risk-factors in cross sectional designs. Based on the vulnerability-stress model, etiologic pathways for depression have been suggested, with vulnerability modifying the effect of stress factors. The current prospective study tests an etiologic model for depression incidence, by assessing modifying effects of three types of vulnerability: genetic/familial vulnerability, organic vulnerability, and environmental vulnerability.

METHODS

1940 non-depressed community-living elderly were interviewed at baseline, and at follow-up three years later. Bivariate and multivariate relationships between risk factors and incident depression (GMS-AGECAT) were studied.

RESULTS

Higher age, personal history of depression, death of spouse, health related factors and comorbid organic or anxiety syndrome showed significant bivariate associations with depression incidence. In multivariate analysis, the effect of stress factors on incident depression was not modified by a genetic/familial vulnerability, nor by an organic vulnerability. Effect modification by environmental factors was however evident; having a marital partner, and if unmarried having social support, significantly reduced the impact of functional disabilities on the incidence of depression.

LIMITATIONS

The study consisted of two measurements with a three years interval, depressive episodes with a short duration may be under-represented.

CONCLUSIONS

In the elderly, the effect of stress on incident depression is modified by environmental vulnerability. No evidence was found of effect modification by either genetic/familial or organic vulnerability. The results have implications for both recognition and treatment of late-life depression.

The incidence of dementia in Canada

Objective: To estimate the incidence of dementia, including AD, among Canadians aged 65 and over.

Methods: A 5-year cohort study of 10,263 seniors was undertaken, including community and institutional samples. The baseline study in 1991 identified 1,132 prevalent cases of dementia through screening and clinical examination. The remaining 9,131 cases formed the incidence study sample and were rescreened and selectively reexamined in 1996. Incident cases were diagnosed using established criteria. Incidence was estimated based on the 1991 population, and included data on those who died between the first and second phases of the study.

Results: Of the nondemented cohort who remained alive in 1996, 5,432 people in the community (88.3%) and 210 (91.3%) in the institutional sample participated in the incidence study. Nine hundred sixty incident cases were identified; the overall age-standardized incidence rates were 21.8 (women) and 19.1 (men) per 1,000 nondemented persons per year. This translates into 60,150 new cases of dementia per year in Canada. The logarithm of the rates rises linearly with age, but suggests a slight slowing of growth in incidence in the oldest age groups.

Conclusions: Our incidence estimates lie toward the upper end of the range of incidence estimates found in other studies. Nonetheless, we calculate that several factors may have biased our estimates downward, suggesting that the incidence of dementia may be higher than many studies have reported.

Three-year prognosis of depression in the community-dwelling elderly

BACKGROUND

Depression is the most common mental disorder in the community-dwelling elderly.

AIMS

To determine the three-year prognosis of depression in a cohort of 127 community-dwelling elderly subjects and identify factors relevant to outcome.

METHOD

The subjects, diagnosed depressed at year 0 using the GMS-AGECAT package, were followed up three years later. A number of factors were investigated for an association with recovery from, or persistence of, depression.

RESULTS

At follow-up, 30.2% of the depressed subjects had died, 34.9% had persistent or relapsed case-level depression, 24.5% had other case- or sub-case-level mental illness and 10.4% had recovered completely. Physical ill-health, bereavement and positive family history of depression were associated with poor outcome, whereas treatment with antidepressant medication significantly improved prognosis.

CONCLUSIONS

Late-life depression in community-dwelling subjects is a chronic condition. However, the positive response to antidepressant medication suggests that it should be vigorously treated.

Epidemiology of major age-related diseases in women compared to men

Many observations indicate that women have a longer life expectancy than men. Population-based studies report that mortality and morbidity are higher in men than in women. The gender difference is constant in cardiovascular disease, cancer and dementia, the more frequent diseases in industrialized countries; these chronic conditions strongly influence longevity and quality of life in old persons. Biological, behavioral and environmental factors emerge as major contributors to the difference in mortality, morbidity and case fatality. However, the causes of gender differences remain poorly understood.

The pattern of psychiatric disorders among the aged in a selected community in Nigeria

OBJECTIVE

To describe the common mental disorders in elderly Nigerians living at home.

METHOD

A house-to-house survey of a rural community was conducted to identify subjects who were aged 60 years and above. The subjects were interviewed with the Self-Reporting Questionnaire (SRQ-24) and the Geriatric Mental State Schedule (GMS). Psychiatric syndromal diagnoses were made with the Clinical and Research ICD-10 manuals (ICD-10/ICD-10, DCR).

RESULTS

The overall rate of major mental disorders was 23.1%, with depression constituting 79% of all the diagnoses. Specific dementia disorders were not found in any of the subjects (N=164), but 20.7% complained of forgetfulness. Use of tobacco (snuff), (local) alcohol, and other substances were common. No subject with any identified disorder was receiving any medical attention.

CONCLUSION

The study reveals the same range of mental disorders as in studies carried out elsewhere. This suggests that if similar methodologies are used, the mental morbidity rates among the elderly in different parts of the world may be about the same. There is a need for adequate planning to accommodate the social security and mental health needs of old Nigerians.

Subthreshold depression in the elderly: qualitative or quantitative distinction?

Recent studies revealed that subthreshold depression (or "subclinical" or "subsyndromal" depression) can have clinical validity because it is related to dysfunction and disability and is a risk factor for major depression. However, none of these studies focused on old age. Therefore, one aim of the psychiatric part of the multidisciplinary Berlin Aging Study (BASE) was also to detect milder forms of psychopathological syndromes, especially subthreshold depression, compared with specified forms such as major depression and dysthymia according to the DSM-III-R. The present evaluation shows that subthreshold depression can be characterized in 2 ways: firstly, as a quantitatively minor variant of depression or a depression-like state with fewer symptoms or with less continuity; and secondly, as qualitatively different from major depression with fewer suicidal thoughts or feelings of guilt or worthlessness, while worries about health and weariness of living occur with a similar frequency.

Late-onset schizophrenia and very-late-onset schizophrenia-like psychosis: an international consensus. The International Late-Onset Schizophrenia Group

OBJECTIVE

Although schizophrenia is generally regarded as an illness with onset in late adolescence or early adult life, a sizeable minority of patients first become ill in middle or old age. Inconsistencies in diagnostic systems and nomenclature, coupled with a tendency among most schizophrenia researchers to ascribe late-onset psychoses to organic factors, have led to such cases occupying an ambiguous position in relation to schizophrenia. Through systematic review of the literature and publication of a consensus statement from an international group of experts in the field, this article aims to clarify the positions of late-onset schizophrenia and very-late-onset schizophrenia-like psychosis.

METHOD

The authors conducted a MEDLINE literature review and developed a consensus statement summarizing the findings from 2 days of debate and discussion by members of the International Late-Onset Schizophrenia Group.

RESULTS

The group achieved consensus on diagnosis, nomenclature, treatment guidelines, and future research directions.

CONCLUSIONS

In terms of epidemiology, symptom profile, and identified pathophysiologies, the diagnoses of late-onset schizophrenia (illness onset after 40 years of age) and very-late-onset schizophrenia-like psychosis (onset after 60 years) have face validity and clinical utility. General adoption of these categories will foster systematic investigation of such patients.

The course of depression in elderly subjects with and without dementia

BACKGROUND

A persistent course of depression has been described in subjects with and without dementia. Up to the present it is unclear to what extent dementia affects the prognosis of depression.

METHOD

At baseline and at 6 and 12 months follow-up AGECAT depression diagnoses were made in 49 subjects with and 72 subjects without DSM-III-R dementia living in homes for the elderly.

RESULTS

Adjusting for demographic characteristics and physical health, dementia was not associated with the severity of depression at follow up. The baseline depression severity and to a lesser extent somatic complaints predicted a bad prognosis of depression in the total sample.

LIMITATIONS

Because of the high vulnerability of the residents the results cannot be generalised to other populations of elderly subjects.

CONCLUSION

Depression is persistent in residents of homes for the elderly. Dementia does not affect its course.

Socio-economic deprivation and the prevalence and prediction of depression in older community residents. The MRC-ALPHA Study

BACKGROUND

The Townsend index is a measure of social deprivation. It can be applied to postal districts and has been employed in studies examining the ecological associations of mental illness.

AIMS

We examine the utility of the Townsend index in identifying older populations with a high prevalence and risk of developing depression.

METHOD

The study was carried out in the context of a cohort study of an age- and gender-stratified sample of 5222 community residents aged 65 years and over. Subjects were interviewed at intervals of two years. The relationships between Townsend score and psychiatric diagnoses (in particular, depression) were examined.

RESULTS

High Townsend scores were associated with increased prevalence and incidence of depression and prevalence of organic psychiatric illness.

CONCLUSIONS

The Townsend index can be used to prioritize psychiatric and primary care resources so as to cater for older populations likely to suffer from depression and organic psychiatric conditions.

Mortality and mental disorders in a Spanish elderly population

OBJECTIVE

To analyse the relationship between mental disorders and mortality rates in the elderly community of Zaragoza, Spain.

METHODS

Baseline, cross-sectional study (two-stage screening) of a representative, stratified sample (N=1080) of the elderly (65+ years) living in the community. Follow-up study (4.5 years).

INSTRUMENTS

Spanish versions of Geriatric Mental State, AGECAT computerized diagnostic program and Mini-Mental Status Examination.

RESULTS

Two hundred and sixteen subjects died during the follow-up period (global mortality rate 4.8% per year). Using a logistic regression model with sex, age, educational level, physical illness and AGECAT diagnoses as explanatory variables and alive/dead as response, the following odds ratios (95% confidence intervals in parentheses) were obtained (reference group: non-cases): 'subcases' 1.3 (0.9-2.0), 'organic' (dementia) 3.7 (2.0-6.7), global depression 3.0 (1.7-5.3), 'psychotic' depression (melancholic type) 3.7 (1.7-8. 4), 'neurotic' depression 2.7 (1.4-5.3) and 'neuroses' 0.8 (0.2-3.6). Both pure 'organic' and pure 'depressed' cases had higher mortality when compared with comorbidity cases.

CONCLUSION

There is a significant association between psychiatric morbidity and mortality in the elderly living in a Spanish community. Mortality risk in psychiatric cases are higher than previously reported in the literature.

Natural history of pharmacotherapy of older depressed community residents. The MRC-ALPHA Study

BACKGROUND

Depression in older people is common and has a high mortality, but effective treatments exist.

AIMS

To describe drug prescribing in older community residents in relation to depression status.

METHOD

The MRC-ALPHA community cohort aged 65 and over were interviewed using the Geriatric Mental State examination drug data collected at index interview and at two and four years.

RESULTS

Antidepressants were used by 10.9% of the depressed population. Benzodiazepines were used frequently. Of the antidepressant users, 59.6% took low-dose antidepressants for two years, had a poor outcome and few drug changes.

CONCLUSIONS

Trends of increasing antidepressant use have cost implications for primary care groups. Benzodiazepines may be mis-prescribed for treatment of depressive symptoms. Antidepressant users have poor outcome and follow-up.

Undifferentiated dementia, Alzheimer's disease and vascular dementia: age- and gender-related incidence in Liverpool. The MRC-ALPHA Study

BACKGROUND

Does incidence of dementia follow the age pattern of prevalence? Is gender a risk factor? Do patterns of incidence differ between dementias?

AIMS

To assess age-specific incidence rates of undifferentiated dementias, Alzheimer's disease and vascular dementia.

METHOD

5222 individuals aged > or = 65 years, were interviewed using the Geriatric Mental State/History and Aetiology Schedule. The AGECAT package was used to identify cases at three interviewing waves at two-year intervals. Diagnoses were made using ICD-10 Research Criteria and validated against neurological and psychological examination, with imaging and neuropathology on unselected subsamples.

RESULTS

Incidence rates of the dementias increase with age. Age patterns are similar between Alzheimer's disease and vascular dementia. Gender appears influential in Alzheimer's disease. In England and Wales, 39,437 new cases of Alzheimer's disease (4.9/1000 person-years at risk); 20,513 of vascular dementia (2.6/1000 person-years) and 155,169 of undifferentiated dementia (19/1000 person-years) can be expected each year.

CONCLUSIONS

Incidence rates for Alzheimer's disease and vascular dementia appear to behave differently, with an increased risk of Alzheimer's disease for women compared to vascular dementia.

Demoralisation, distress and pain in older Western Australians

OBJECTIVE

To assess the relationship of psychiatric morbidity, morale, physical activity and the presence of pain in older people.

METHOD

Older people attending senior citizens' clubs were administered the 28-item General Health Questionnaire (GHQ-28), the Revised Philadelphia Geriatric Centre Scale (RPGCS) and five self-report questions from the Brief Disability Questionnaire. They also rated the presence of pain on a five-point scale. Multiple and logistic regression were used to adjust for socio-demographic factors and identify variables independently associated with psychological status and morale.

RESULTS

Of 112 people approached, 86% agreed to take part (n = 96). The sample showed a wide range in total GHQ scores (mean = 2.9, range = 0-19) and RPGCS scores (mean = 2.3, range = 1.1-3.0). Twenty-one per cent had psychological distress as defined by a score of > or = 6 on the GHQ-28 (n = 19). Fifty-four respondents (56%) reported low morale as defined by a score < 2 on the RPGCS. There was a close relationship between psychological distress, low morale on the RPGCS (OR = 5.5 [1.5-20.5]) and moderate to severe pain (OR = 5.3 [1.8-15.9]). When adjusted odds ratios were calculated to control for confounding factors, moderate to severe pain remained independently associated with psychological distress (OR = 1.6 [1.3-2.4] p = 0.02), and limitations in daily activities with low morale (OR = 3.64 (1.001-8.4) p = 0.05).

CONCLUSIONS

There is a close relationship between physical disability, low morale and psychological distress.

IMPLICATIONS

An increased index of suspicion for psychological distress is warranted in all older people with physical disability, particularly in the presence of moderate to severe pain.

Community-based case-control study of depression in older people. Cases and sub-cases from the MRC-ALPHA Study

BACKGROUND

Risk factors of depression in later life, particularly for sub-cases and for psychotic and neurotic types of depression, are unclear.

AIMS

To identify such risk factors.

METHOD

Over 5200 older people (> or = 65 years), randomly selected from Liverpool, were interviewed using the Geriatric Mental State (GMS) and the Minimum Data Set (MDS). The computer-assisted diagnosis AGECAT identified 483 cases and 575 sub-cases of depression and 2451 with no mental problems. Logistic regression was employed to examine factors relevant to caseness.

RESULTS

In multiple logistical regression, odds ratios (ORs) were significantly high for being female (2.04, 95% CI 1.56-2.69), widowed (2.00, 1.18-3.39), having alcohol problems (4.37, 1.40-2.94), physical disablement (2.03, 1.40-2.94), physical illness (1.98, 1.25-3.15), taking medications to calm down (10.04, 6.41-15.71), and dissatisfaction with life (moderate 4.54, 3.50-5.90; more severe 29.00, 16.00-52.59). Good social networks reduced the ORs. If sub-cases were included as controls, the statistical significance was reduced.

CONCLUSIONS

Age was not associated with depression in later life whereas gender, physical disablement and dissatisfaction with life were. The sub-cases shared many risk factors with cases, suggesting that prevention may need to be attempted at an early stage.

Prevalence and correlates of depression among Saudi elderly

OBJECTIVES

To assess the prevalence of depression and associated factors in elderly people in Saudi Arabia.

METHOD

A cross-sectional national survey of the elderly population of Saudi Arabia was conducted between January 1994 and December 1995. A stratified two-stage sampling technique was used to select the study subjects. In the first stage, a random sample of primary health care centres (PHCs) was selected in each of the five administrative regions of the country. The family health records (FHR) of each selected PHC were reviewed and a list of the elderly (60 years and over) was compiled. In the second stage, a sample of the subjects was selected from the FHR and contacted for a personal interview. The subjects' physical, social and environmental health status were assessed by an interview during which a structured questionnaire was completed. The Geriatric Depression Scale (GDS) was used to screen for depression. Other items of information in the questionnaire included subjects' sociodemographic characteristics, activities of daily living (ADL), laboratory and radiological investigations.

RESULTS

The total number of elderly subjects included in this study was 7970. Their mean age+/-standard deviations was 68.8+/-7.7 (male 69.1+/-.7.7; and female 67.7+/-7.5) years. Depressive symptoms were reported in 3110 (39%) of the subjects, and 8.4% were in the severe depressive symptoms score group. Personal characteristics that correlated strongly with depression were poor education (p=0.001), unemployment (p=0.001), divorced or widowed status (p=0.001), old age and being a female (p=0.001). Living in a remote rural area with poor housing arrangements and limited accessibility within the house and poor interior conditions were also significantly associated with high depressive symptoms (p=0.001). Limited privacy, such as having a particular room specified for the elderly, was associated with more depressive symptoms than sharing a room with another person (p=0. 001). Lower incomes inadequate for personal needs as well as depending on charity or other relatives were associated with more cases of depression (p=0.001). The proportion of cases of depression correlated positively with the number of medical diagnoses and medications received (p=0.001). Significant depression was associated with loss of a close relative, living alone and limited participation in recreational activities. Perception of poor health and dependence on others for daily activities were associated with more depressive symptoms (p=0.001). Also health problems, especially faecal or urinary incontinence, were associated with more depressive symptoms (p=0.001).

CONCLUSION

Depressive symptoms are common among Saudi elderly. Detection and management rates were low. Primary care teams could help these patients if properly trained. A simple instrument such as the Geriatric Depression Scale is useful and easily administered.

Follow-up study of depression in the elderly. Clinical and SPECT data

BACKGROUND

Imaging studies in depression of the elderly are often small and highly selective.

AIMS

To investigate a large group of elderly depressed patients in order to assess changes in clinical, imaging and neuropsychological variables at follow-up.

METHOD

Patients (n = 175, age range 65-91 years) with clinical depression were identified from consecutive local referrals. Clinical interviews, neuropsychological tests and SPECT scans were carried out at referral and at two-year follow-up.

RESULTS

Of 84 re-examined patients, 46.5% were well, 9.5% were ill, 33% partially recovered and 11% had developed dementia. Duration of illness before index assessment was the only factor to predict outcome. Thirty-nine patients could be scanned and followed up. There were no differences between patients with good or poor depressive outcome on SPECT. Ten clinically improved patients could be re-examined with SPECT. There were relative increases in right cingulate gyrus and right cerebellum at follow-up.

CONCLUSIONS

The patients group was comparable with other studies showing high levels of residual depressive symptoms. Activity changes in limbic cortex are implicated in depression of old age.

No association between an intronic polymorphism in the presenilin-1 gene and Alzheimer disease in a German population

A polymorphism in intron 8 of the presenilin-1 (PS-1) gene has been demonstrated to increase the risk for developing late-onset Alzheimer disease (AD). Conflicting results exist for the association between this intronic polymorphism and AD probably due to variations in the PS-1 gene among different ethnic groups. We investigated the genetic association between this intronic polymorphism in the PS-1 gene and AD in a homogenous group of German Caucasians. The control group consisted of healthy subjects and depressed patients. There were no significant differences in the distribution of the PS-1 genotypes and allele frequencies between AD patients and controls. Our data do not support an association between the intronic polymorphism of the PS-1 gene and AD and there was no interaction between the PS-1 genotype and apolipoprotein E epsilon4 allele.

Prognosis of depression in elderly community and primary care populations: a systematic review and meta-analysis

OBJECTIVE

The purpose of this study was to determine the prognosis of depression in elderly community and primary care populations.

METHOD

MEDLINE and PsycINFO were searched for potentially relevant articles published from January 1981 to November 1996 and from January 1984 to November 1996, respectively. The bibliographies of relevant articles were searched for additional references. Twelve studies met the following five inclusion criteria: original research, published in English or French, study population of community residents or primary care patients, subjects' mean age 60 years and over, and reported affective state as an outcome. The validity of the studies was assessed according to the criteria for prognostic studies described by the Evidence-Based Medicine Working Group. Information about the population, proportion of depressed subjects detected and treated by primary care physicians, length of follow-up, outcomes, and prognostic factors was systematically abstracted from each report.

RESULTS

All of the studies had some methodologic limitations. A meta-analysis of outcomes at 24 months estimated that 33% of subjects were well, 33% were depressed, and 21% had died. There was statistically significant heterogeneity in the outcomes across studies. The length of follow-up and lower age limit for enrollment explained part of the heterogeneity for the percent well but not for the other outcomes. Physical illness, disability, cognitive impairment, and more severe depression were associated with worse outcomes but inconsistently so.

CONCLUSIONS

Depression in elderly community and primary care populations has a poor prognosis, is perhaps chronic or relapsing or both, and is probably undertreated. Despite the methodologic limitations of the studies and this meta-analysis, these findings seem to support efforts to develop detection and treatment programs for depression in these populations.

Hypertension and dementia

Vascular dementia (VD) is more prevalent than Alzheimer's disease (AD) in Japan, while AD is more common in Western countries. In the Hisayama study, a community-based cohort study of Japan, the prevalence of VD decreased in men during the 7-years (1985-1992) follow-up period, while the prevalence of AD remained unchanged both in men and women. The incidence of dementia increases with age, particularly AD aged 85 or older. Hypertension is a major risk factor for VD. Other risk factors include age, prior stroke, diabetes, alcohol intake, heart disease, and smoking. In contrast, age, a family history of dementia, a low educational level, and low physical activity are risk factors for AD. The role of hypertension in AD remains controversial; there has been positive, negative, or no association existed between blood pressure levels and AD. A recent clinical trial has disclosed the potential preventive effect of antihypertensive treatment on the incidence of dementia, especially of AD. Although the role of vascular factors for the pathogenesis of AD is becoming recognized, the effectiveness of antihypertensive treatment on the prevention of AD should be further clarified in the future studies.

Child outcomes when child care center classes meet recommended standards for quality. NICHD Early Child Care Research Network

OBJECTIVES

This study assessed outcomes for children when child care centers meet recommended care standards.

METHODS

Data from the NICHD Study of Early Child Care were used to examine the association between meeting standards for child-staff ratios, group sizes, caregiver training, and caregiver education and children's development at 24 and 36 months of age.

RESULTS

There were 5 major findings: (1) most classes observed did not meet all 4 recommended standards (compliance ranged from 10% at 6 months of age to 34% at 36 months of age); (2) linear associations were found between number of standards met and child outcomes, and this was more the case at 36 months than at 24 months of age: (3) there was no evidence of threshold effects; (4) children in classes that met more standards had better school readiness and language comprehension scores as well as fewer behavior problems at 36 months of age; and (5) child outcomes were predicted by child-staff ratio at 24 months and caregiver training and education at 36 months of age.

CONCLUSIONS

Outcomes were better when children attended classes that met recommended child-staff ratios and recommended levels of caregiver training and education.

The importance of subsyndromal depression in older primary care patients: prevalence and associated functional disability

OBJECTIVE

Existing diagnostic categories for depression may not encompass the majority of older people suffering clinically significant depressive symptoms. We have described the prevalence of subsyndromal depressive symptoms and tested the hypothesis that patients with subsyndromal depression have greater functional disability and general medical burden than nondepressed subjects but less than patients with diagnosable depressions.

METHODS

Subjects were 224 patients, aged 60 years and older, recruited from private internal medicine offices or a family medicine clinic. Validated measures of psychopathology, medical burden, and functional status were used. The subsyndromal depression group was defined by a score of more than 10 on the Hamilton Rating Scale for Depression and by the absence of major or minor depressive disorder. Analyses included multiple regression techniques to determine the presence of group differences adjusted for demographic covariates.

RESULTS

Subsyndromal depression was common (estimated point prevalence of 9.9% compared with 6.5% for major depression, 5.2% for minor depression, and .9% for dysthymic disorder), associated with functional disability and medical comorbidity to a degree similar to major or minor depression, and often treated with antidepressant medications.

CONCLUSIONS

Although depressive conditions are common and are associated with considerable functional and medical morbidity in older primary care patients, many patients with clinically significant depressive symptoms are not captured by criteria-based syndromic diagnostic categories. Future work should include intervention studies of subsyndromally depressed older persons as well as attention to the course and biopsychosocial concomitants of diagnosable and subsyndromal depressions in this population.

A genetic variation of the inflammatory cytokine interleukin-6 delays the initial onset and reduces the risk for sporadic Alzheimer's disease

Local inflammatory processes surrounding the amyloid plaques contribute to the progression and acceleration of the Alzheimer's disease (AD)-related neurodegeneration. Interleukin-6 (IL-6) is an inflammatory cytokine with possible involvement in the local immune response occurring in the central nervous system of AD patients. We tested the hypothesis as to whether a genetic polymorphism of the IL-6 gene (IL-6) modifies the age at onset and risk for sporadic AD. Our results support an association of the C allele of the IL-6 genotype with a delayed initial onset and reduced disease risk and indicate that genetically determined alterations of the immune response may modify the course of AD.

Orthostatic hypotension and cognitive decline in older people

OBJECTIVES

To establish the role of orthostatic hypotension (OH) as a risk factor for cognitive decline among home-dwelling and institutionalized older people and to describe other predictors of cognitive decline.

DESIGN

Follow-up study with two clinical examinations.

SETTING

A community-based setting in northern Finland.

PARTICIPANTS

All of the 1159 people aged 70 or more living in five rural municipalities around the town of Oulu in Northern Finland in 1991. At the time of the follow-up examination, 2.5 years later, 884 of the original participants were alive and 651 were re-examined.

MEASUREMENTS

In 1991, 907 people (78.3% of the total population) were tested for orthostatic hypotension, and their cognitive capacity was assessed with the Mini-Mental State Examination (MMSE). The calculation/spelling tasks were excluded from the final version used in the statistical analysis. The re-assessment of cognitive capacity was made on 651 subjects (73.6% of those alive) who had participated in the first examination. The data were analyzed using polychotomous and linear regression analysis models.

RESULTS

The prevalence of OH was 28.7%, with no age or sex differences. The mean sum score for the shortened MMSE in 1991 was 21.6 (+/-3.98) for persons with OH and 21.1 (+/-4.08) for non-OH persons. During the follow-up, the sum score declined in the OH group by .44 (+/-2.81) points and in the non-OH group by .83 (+/-3.61) points. No type of OH (systolic or diastolic 1- or 3-minute values or their combination) predicted cognitive decline; the only predictors were old age and low level of formal education.

CONCLUSIONS

Orthostatic hypotension is a common clinical condition that affects every fourth person aged 70 years or older. By temporarily inducing cerebral hypoperfusion, it may cause or exacerbate cognitive dysfunction. In an unselected population, OH was not associated with cognitive deterioration, nor did it predict cognitive decline during a 2-year follow-up.

Cross-cultural comparison of depressive symptoms in Europe does not support stereotypes of ageing

BACKGROUND

Stereotypes of older people suggest that they are depressed.

AIMS

To examine depression symptoms among people aged > or = 65 in the general population and to ask the following questions. Are there high proportions of depressive symptoms among otherwise well people? Do these levels reflect the prevalence of depression? Do key symptoms vary with age and do they confirm stereotypes?

METHOD

Nine centres contributed data from community-based random samples, using standardised methods (GMS-AGECAT package).

RESULTS

Proportions of depressive symptoms varied between centres. Some often associated with ageing were rare. Many were more common in women. Low-prevalence centres tended to have fewer symptoms among 'well' people, but there were inconsistencies. Low levels of symptoms among the well population of a centre did not necessarily predict lower levels in the depressed.

CONCLUSIONS

Variations in the prevalence of depressive symptoms occurred between centres, not always related to levels of illness. There was no consistent relationship between proportions of symptoms in well persons and cases for all centres. Few symptoms were present in > 60% of the older population--stereotypes of old age were not upheld.

Depression in Europe. Geographical distribution among older people

BACKGROUND

This is the first report of results from the EURODEP Programme.

AIMS

To assess the prevalence of depression judged suitable for intervention in randomised samples of those aged > or = 65 in nine European centres.

METHOD

The GMS-AGECAT package.

RESULTS

Differences in prevalence are apparent, 8.8% (Iceland) to 236% (Munich). When sub-cases and cases are added together, five high- and four low-scoring centres emerge. Women predominated over men. Proportions of sub-cases to cases revealed striking differences but did not explain prevalence. There was no constant association between prevalence and age. A meta-analysis (n = 13,808) gave an overall prevalence of 12.3%, 14.1% for women and 8.6% for men.

CONCLUSIONS

Considerable variation occurs in the levels of depression across Europe, the cause for which is not immediately obvious. Case and sub-case levels taken together show greater variability, suggesting that it is not a matter of case/sub-case selection criteria, which were standardised by computer. Substantial levels of depression are shown but 62-82% of persons had no depressive level. Opportunities for treatment exist.

Genetic polymorphism of cathepsin D is strongly associated with the risk for developing sporadic Alzheimer's disease

The beta amyloid peptide derives from its precursor protein via proteolytic cleavage of yet unidentified proteases (beta- and gamma-secretases). Cathepsin D is an intracellular protease with in-vitro beta-secretase-like features. An exonic polymorphism of the cathepsin D gene (alanine to valine transition at position 224, exon 2) has been associated with altered enzyme function. We tested the hypothesis that this polymorphism is associated with an increased risk for Alzheimer's disease in 102 demented patients, 191 healthy subjects, and 160 depressed patients. There was a highly significant overrepresentation of the cathepsin D*T allele in demented patients (14.2%) compared to non-demented controls (6.7%, P = 0.0012). Carriers of the cathepsin D*T allele had a 2.4-fold increased risk for developing AD than non-carriers. Carriers of the apolipoprotein E epsilon 4 allele had a 4.1 -fold increased risk than non-carriers. The odds ratio for subjects with the apolipoprotein E epsilon 4 and the cathepsin D*T allele was 5.9. Our data suggest that the cathepsin D genotype is strongly associated with the risk for Alzheimer's disease.

Depression, cerebral atrophy, cognitive performance and incidence of dementia. Population study of 85-year-olds

BACKGROUND

Hospital-based studies suggest that depression in old age relates to organic brain changes.

AIMS

To determine whether these findings are confirmed in a population-based sample.

METHOD

A population sample of non-demented 85-year-olds (227 mentally healthy and 62 with DSM-III-R depression were given a neuropsychiatric examination and computerised tomographic scans of the brain, and followed for three years.

RESULTS

On the Mini-Mental State Examination, those with a low educational level with major depression performed worse than the mentally healthy; this distinction was not evident among those who had received higher education. Measures of brain atrophy were similar in depressed and mentally healthy individuals. The three-year incidence of dementia was increased in those with early-onset major depression.

CONCLUSIONS

Higher education may protect against cognitive symptoms in depressed individuals. The association between depression and cerebral atrophy in the elderly is not very strong. The higher incidence of dementia in those with early-onset major depression may be due to a longer lifetime duration of depression, emphasising the importance of detecting and treating depression in the community.