MRI and neuropsychological differences in early- and late-life-onset geriatric depression

Late-life depression, religiosity, cerebrovascular disease, cognitive impairment and attitudes towards death in the elderly: Interpreting the data

Geriatric depression is considered to be a major health problem in the elderly. Passing the age, the speed of mental process is decreasing and personality obtains more mature functioning (better coping) while most of its traits remain stable. Empirical studies have shown that fear of death is most prominent during midlife and not late-life. Neuroimaging studies led to the "vascular depression" hypothesis. Depression was found to be a strong predictive factor leading to stroke, while religiosity seemed to be a 'protective' factor. A possible interpretation of these reports could consider late-life depression to be an early symptomatology of an undergoing vascular disease. Religiosity could be interpreted as absence of depression, and therefore, mainly as absence of vascular lesions. The above have profound implications in the understanding of late-life depression and to the therapeutic design, especially in the primary care setting.

Treatment outcomes for older depressed patients with earlier versus late onset of first depressive episode: a Sequenced Treatment Alternatives to Relieve Depression (STAR*D) report

OBJECTIVE

Controversy exists whether age at onset of the first depressive episode predicts chance of response and remission or the timing of such outcome. In this study of older depressed outpatients, the authors evaluated whether the age at onset of the first major depressive episode (MDE) was related to clinical outcomes.

DESIGN

Post-hoc dataset analysis for older participants treated with citalopram in the Sequenced Treatment Alternatives to Relieve Depression trial was performed. Side effects, remission rates, and baseline characteristics were compared for participants whose first MDE began at or before age 55 (earlier onset) versus those with their first MDE after age 55 (late onset).

SETTING

Participants were enrolled from 23 psychiatric and 18 primary care settings.

PARTICIPANTS

There were 574 treatment-seeking outpatients (age range: 55-75 years) with nonpsychotic major depressive disorder who had a baseline 17-item Hamilton Rating Scale for Depression score of > or =14.

INTERVENTION

Participants received citalopram treatment for up to 14 weeks.

MEASUREMENTS

Remission was defined by a 16-item Quick Inventory of Depressive Symptomatology-Self-Rated score of < or =5 at study exit. Side effects were measured by the Frequency, Intensity, and Burden of Side Effects Rating.

RESULTS

Of 574 participants, 72.1% had earlier-onset depression and 27.9% had late-onset depression. Remission rates were not statistically different between earlier-onset (30.8%) and late-onset (31.9%) participants. Time to remission did not differ as well.

CONCLUSION

The self-reported age at onset of the first MDE being after age 55 was not related to clinical outcomes for participants 55 to 75 years of age.

The cognitive neuropsychology of depression in the elderly

BACKGROUND

The cognitive impairment of older depressed patients with late- as opposed to early-onset illness may show important differences, in that patients with early onset may suffer predominantly from impaired episodic memory, and those with late onset mainly from reductions of executive function and processing speed.

METHOD

We searched Medline and EMBASE as well as individual papers' reference lists for relevant publications, recording comparisons in neuropsychological test results between early-onset depression (EOD), late-onset depression (LOD) and healthy volunteers. Effect sizes are presented for cognitive domains, such as executive function, processing speed, episodic memory, semantic memory and mental state examination.

RESULTS

Patients with LOD showed greater reductions in processing speed and executive function than patients with EOD and controls. Both patient groups showed reduced function in all domains, except mental state, compared with controls.

CONCLUSION

Pronounced executive deficits are typical of the late-onset patients described in published studies, while episodic memory impairment is not specific to early-onset illness. Possible reasons and confounders are discussed.

Subcortical ischaemic changes in young hypertensive patients: frequency, effect on cognitive performance and relationship with markers of endothelial and haemostatic activation

Information on subcortical ischaemic changes (SIC) in young hypertensive patients is scarce. We evaluated the frequency of SIC at magnetic resonance imaging (MRI), the possible effect on cognition of these patients, and the role of plasma markers known as indicators of endothelial and haemostatic activation. Inclusion criteria were age <or=54 years, hypertension for at least 2 years and absence of cerebrovascular disease or other conditions possibly related to SIC. Patients with SIC at MRI and two control groups (matched for age, sex and education) of hypertensive patients without SIC and non-hypertensive healthy subjects underwent an extensive neuropsychological examination and evaluation of plasma markers. Amongst the 200 patients evaluated, 50 (25%) showed SIC at MRI. Mean age was 48.4 +/- 4.8 years. Compared with both control groups, hypertensive patients with SIC performed significantly worse in general cognition, attention, memory and executive functions. Moreover, they showed significantly more often increased levels of all plasma markers compared with healthy controls, and of von Willebrand factor (vWF) compared with both control groups (P < 0.001). In young hypertensive patients SIC are frequent, related to a worse cognitive performance and endothelial dysfunction. Our findings suggest vWF as marker of end-organ damage, underscoring the relevance of treating hypertension at younger age.

Response inhibition predicts poor antidepressant treatment response in very old depressed patients

OBJECTIVE

There have been mixed findings regarding the prognostic significance of age of onset, executive dysfunction, and hyperintensity burden on treatment outcome in late-life depression.

METHODS

Growth curve models were fit to data from the only 8-week, double-blind, placebo controlled trial of citalopram (20-40 mg/day) in patients aged 75 years and older with unipolar depression. Baseline assessment included Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (to determine age at onset), Stroop Color-Word Test (to assess the response inhibition component of execution dysfunction), and structural magnetic resonance imaging (to determine hyperintensity burden).

RESULTS

In the citalopram condition, patients with response inhibition (most impaired quartile) scored higher at endpoint than those without response inhibition. There were no effects for age of onset or hyperintensity load on response in the citalopram condition. In the placebo condition, patients with early-onset depression had higher depression scores at endpoint than patients with late-onset depression.

CONCLUSION

Only response inhibition, a fundamental executive function, predicted poor treatment response to antidepressant medication. Although patients with response inhibition also showed deficits in reaction time, adjusting for reaction time in our final response inhibition model did not substantively change the findings.

Early-life risk factors for late-onset depression

OBJECTIVE

To assess differences between women with no history of depression (No MDD), early-onset depression (EOD), and late-onset depression (LOD) on psychosocial risk factors (marital conflict and lack of social support), neuroticism, and overall self-rated health.

METHOD

Diagnostic data from a community-based longitudinal study of women at mean ages 39, 42, 48, and 59 was used to create three groups of women (No MDD, EOD and LOD). These groups were then compared on psychosocial, personality, and overall health risk assessed approximately 10 years prior to diagnosis.

RESULTS

There were no differences between the groups on marital conflict and social support. Those with EOD scored higher than those in the LOD and No MDD groups on neuroticism. Importantly, those with LOD reported poorer health than those with No MDD 10 years prior to diagnosis.

CONCLUSIONS

These findings provide support for the notion that poor health and not psychosocial risk factors or neuroticism predispose otherwise healthy adults to developing depression for the first time in late-life.

[Validity of vascular depression as a specific diagnostic: a review]

INTRODUCTION

A number of authors have suggested that cerebrovascular disease may predispose, precipitate, or perpetuate some geriatric depressive syndromes. These "vascular depressions" may result from damage of striato-pallido-thalamo-cortical pathways which frequently occurs in cerebrovascular disease.

METHOD

We have searched the English and French literature published between 1996 (when the "vascular depression" hypothesis was first stated) and December 2004 through the Medline computer database and examined the validity of the concept of "vascular depression" thanks to four levels of validity: face validity, descriptive validity, construct validity and predictive validity. The face validity is the extent to which experts agree about the existence of a nosological entity.

RESULTS

The reviews published in this field broadly support the concept of "vascular depression" as a specific disorder. However many authors highlighted the fact that depression has been shown to precede vascular diseases and that depression and vascular diseases may both share some pathogenic or genetic determinants. These interactive and co-morbid relationships between depression and cerebrovascular diseases are difficult to disentangle. The descriptive validity refers to the degree of the clinical specificity of a disorder. It appears only moderate regarding the clinical studies carried out on this issue. However, a late-onset, the absence of a family history of mental illness, the lack of insight, lassitude, psychomotor retardation, a greater disability and particular neuropsychological dysfunctions may be associated with vascular depression. The construct validity, which refers to the degree to which the physiopathological processes involved in an illness are understood, appears difficult to establish because of the complex interactive relationships between cerebrovascular disease and depression. However, cerebrovascular diseases may contribute to the occurrence of depressive symptoms independently of its psychosocial burden. The predictive validity refers to the degree to which a syndrome is characterized by a specific response to treatment or a specific natural history. As regards response to treatment, vascular depression appears rather specific in the sense of a worse response to antidepressants and electroconvulsive therapy. The studies on the natural history of vascular depression lead to inconsistent results. According to some authors, this relative resistance to treatment may be explained by structural rather than functional, and thus potentially irreversible disruption in neural networks.

CONCLUSION

In conclusion, the systematic review of the validity of vascular depression broadly supports this concept. However, further studies are needed to decipher the relationships between depression and cerebrovascular disease. Finally, we suggest that it could be more relevant for future researches in this field if the diagnostic criteria for vascular depression were narrowed and required the presence of both neuro-imaging changes and cerebrovascular disease.

Hippocampal volume and subcortical white matter lesions in late life depression: comparison of early and late onset depression

BACKGROUND

Reduced hippocampal volume and increased prevalence of subcortical white matter lesions are associated with both recurrent early onset depression (EOD) and late onset depression (LOD). It is not clear whether these two factors differentially affect the age of onset of first depression. Therefore, we wished to investigate the relationship between age of first depression onset and hippocampal volume, with adjustment for subcortical white matter lesions.

METHODS

MRI brain scans were used to compare hippocampal volumes and white matter lesions between age matched female patients (>60 years) with recurrent EOD and LOD and healthy controls.

RESULTS

When comparing the three groups and adjusting for age, the Mini-Mental State Examination score, total brain volume and total hippocampal volume were significantly smaller in patients with EOD compared with controls (5.6 vs 6.1 ml; p = 0.04). The prevalence of larger subcortical white matter lesions was higher in patients with LOD compared with patients with EOD (47% vs 8%; p = 0.002). Patients with LOD did not differ in hippocampal volume from patients with EOD or from controls.

CONCLUSIONS

In late life depression, age of first depression onset may distinguish between different independent neuropathological mechanisms. A small hippocampus volume may be a neuroanatomical marker of EOD depression and larger subcortical white matter lesions could be an intermediate between cerebrovascular disease and LOD.

Neuroimaging of white matter in aging and dementia

Clinical neuroscientists have focused increasing attention on white matter connections in the brain and on the effects of aging and disease on these connections. Recent advances in magnetic resonance imaging (MRI) analysis have given researchers new tools for quantifying and visualizing white matter to better relate white matter structure and function. The goals of this article are (a) to acquaint the reader with both established and newer methods for imaging and quantifying white matter anatomy and pathology; and (b) to review recent findings on white matter pathology in aging and dementia. Computer-assisted quantification appears to offer better statistical power than visual rating scales for detecting these relationships. New MR modalities such as diffusion imaging can detect white matter abnormalities not shown with conventional acquisition sequences. These newer techniques hold promise for early detection of disease and for delineating functional connections between brain areas.

Semantic clustering indexes for the Hopkins Verbal Learning Test-Revised: initial exploration in elder control and dementia groups

This study examined the validity of semantic clustering indexes developed for the Hopkins Verbal Learning Test-Revised (HVLT-R). Participants were healthy adults and patients diagnosed with probable dementia of the Alzheimer's type (DAT) or vascular dementia (VaD). Neuropsychological test records, which included the HVLT-R, were collected from an archival database. Ratio semantic clustering (RSC) scores were calculated for each HVLT-R recall trial. Factor analysis including RSC and other HVLT-R scores yielded high loadings of RSC scores on a distinct clustering factor. Group comparisons showed that normal controls had higher HVLT-R recall and RSC scores than DAT and VaD patients. Only the DAT group showed significant decline in RSC from the final learning trial to delayed recall, and only the DAT group performed more poorly than controls on other semantic processing measures (e.g., HVLT-R semantically-related false positives, Boston Naming Test). Results suggest that these newly developed semantic clustering indexes are easily calculated and potentially useful for discriminating between elder controls and dementia patients.

Current perspectives on management of co-morbid depression in COPD

Individuals with COPD have a higher prevalence of co-morbid depression than either the general population or patients with other chronic illnesses. The best estimates report a prevalence of approximately 40% in COPD patients, compared to 15% in the general population. Depression in COPD patients leads to a lower quality of life, greater objective impairment in function, and decreased adherence to therapeutic interventions. While many depressed COPD patients have been treated empirically with antidepressants--subjecting them to antidepressant side effects, toxicities, and costs--there is a surprising lack of evidence supporting or directing that treatment. We review the current literature regarding the management of depression in COPD, suggest strategies for management, and future research needs.

“Vascular Depression” Predicts Verbal Fluency in Older Adults

Past research has found links among cerebrovascular risk factors (CVRFs), depression, and cognition in older adults. This study investigated how well baseline cerebrovascular burden and depression predicted verbal fluency three and six months later. Participants were 139 medical rehabilitation patients, age 60 and above. The Geriatric Depression Scale, Charlson Co-Morbidity Index, and Dementia Rating Scale were administered at baseline, and verbal fluency was measured three and six months later. Structural equation modeling found that depression significantly predicted verbal fluency at both time points, independently of demographic variables, baseline cognition, or medical burden. CVRFs correlated with depressive symptoms but did not independently predict verbal fluency. Findings suggest that vascular depression may be a possible signal of impaired brain integrity, consistent with Alexopoulos and colleague's (2000) conceptual framework.

Psychiatric disease in the twenty-first century: The case for subcortical ischemic depression

The current approach to psychiatric diagnoses involves identifying symptom clusters that fit a specific syndrome. Although this approach has facilitated the field's development, advances in genetics and neuroimaging raise the question of how causality may fit into the diagnostic process. One approach would be a two-axial system, wherein clinical presentation is on one axis and putative risk factors are on the other. This approach applies to subcortical ischemic depression (SID), a diagnosis corresponding to the "vascular depression" hypothesis. Subcortical ischemic depression affects clinical presentation, long-term outcomes, and response to antidepressant therapy, arguing that it is a valid diagnostic entity worth further study.

Vascular depression: A distinct diagnostic subtype?

Vascular depression has been proposed as a unique and valid diagnostic subtype on the basis of studies of external (concurrent and predictive) validity. Validating a diagnostic entity on the basis of external validity is problematic, because it presupposes that the construct is well defined (i.e., the proposed features cluster together to define a distinct patient group). Because such evidence has not been obtained, we propose that the next critical step in evaluating this potential subtype is to establish internal (construct) validity and highlight taxometric analysis and latent class cluster analysis as illustrative multivariate statistical techniques that can be used in this effort. The psychometric approach advocated here (despite its inherent assumptions and limitations) might substantially improve on previous diagnostic efforts (e.g., expert consensus), and vascular depression might serve as a prototype for future psychiatric classification.

Is depression different in older adults?

Psychiatric disorders such as depression are common conditions in older adults. Depression presents similarly to younger adults, but with more psychotic symptoms and apathy. Research has suggested that genetics play a less important role in the etiology of depression in the elderly, but that other biological factors may be more significant. Vascular pathology in particular is thought to be especially important. White-matter hyperintensities are found in the frontal lobes and basal ganglia in greater numbers in older adults with depression, with damage to the frontal–subcortical circuits thought to be particularly important. It is associated with treatment resistance. Prognosis is poor if depression is not detected and treated adequately and this may lead to a higher risk of dementia and death. However, treatment with selective serotonin reuptake inhibitors and other antidepressants, plus psychological therapies, are effective in the older depressed patient and reduce morbidity and mortality.

Evolution of Prevalence of Depressive Symptoms and Antidepressant Use Between 1988 and 1999 in a Large Sample of Older French People: Results from the Personnes Agées Quid Study

OBJECTIVES

To describe the evolution of prevalence of depressive symptoms and antidepressant use between 1988 and 1999 in a large representative sample of older community-dwelling French people.

DESIGN

Prospective cohort designed in 1988/89 to study cerebral and functional aging.

SETTING

Urban and rural communities in southwestern France.

PARTICIPANTS

Three thousand six hundred thirty-seven adults aged 65 and older living in noninstitutional settings at baseline.

MEASUREMENTS

Participants were interviewed 3, 5, 8, and 10 years after the initial data collection. Depressive symptomatology was evaluated using a French version of the Center for Epidemiological Studies Depression Scale. Longitudinal analysis of the prevalence of depressive symptomatology was performed using a logistic mixed model adjusted for antidepressant use, sex, age, education level, living conditions, psychiatric antecedents, drug consumption, and diagnosis of dementia.

RESULTS

Over the 10 years of follow-up, the prevalence of depressive symptomatology decreased from 13.8% to 8.3%. This decrease was statistically significant even after adjustment (odds ratio = 0.88 per increased year, 95% confidence interval = 0.85-0.90) and was more pronounced in subjects having reported previous depression at baseline. During the same period, antidepressant use rose from 5.2% to 11.9%, mainly due to increased use of selective serotonin reuptake inhibitors. Furthermore, the proportion of subjects who had depressive symptoms and did not use antidepressants decreased from 11.8% to 6.2%.

CONCLUSION

This study suggests better management of late-life depression in the last decade and illustrates the heterogeneity of depression disorder in late life.

Neuroimaging in late-life depression

Late-life depression may be associated with vasculopathy. Neuroimaging has been a critical tool in exploring the relationship between this form of depression and vascular factors. Magnetic resonance imaging has been the most widely used tool, but there is potential to use other structural imaging techniques as well as functional neuroimaging methodologies. Neuroimaging may potentially be utilized at some point as a biomarker for late-life depression, thus helping with diagnosis and guiding treatment.

Multifractal analysis of deep white matter microstructural changes on MRI in relation to early-stage atherosclerosis

Multifractal analysis based on generalized concepts of fractals has been applied to evaluate biological tissues composed of complex structures. This type of analysis can provide a precise quantitative description of a broad range of heterogeneous phenomena. Previously, we applied multifractal analysis to describe heterogeneity in white matter signal fluctuation on T2-weighted MR images as a new method of texture analysis and established Deltaalpha as the most suitable index for evaluating white matter structural complexity (Takahashi et al. J. Neurol. Sci., 2004; 225: 33-37). Considerable evidence suggests that pathophysiological processes occurring in deep white matter regions may be partly responsible for cognitive deterioration and dementia in elderly subjects. We carried out a multifractal analysis in a group of 36 healthy elderly subjects who showed no evidence of atherosclerotic risk factors to examine the microstructural changes of the deep white matter on T2-weighted MR images. We also performed conventional texture analysis, i.e., determined the standard deviation of signal intensity divided by mean signal intensity (SD/MSI) for comparison with multifractal analysis. Next, we examined the association between the findings of these two types of texture analysis and the ultrasonographically measured intima-media thickness (IMT) of the carotid arteries, a reliable indicator of early carotid atherosclerosis. The severity of carotid IMT was positively associated with Deltaalpha in the deep white matter region. In addition, this association remained significant after excluding 12 subjects with visually detectable deep white matter hyperintensities on MR images. However, there was no significant association between the severity of carotid IMT and SD/MSI. These results indicate the potential usefulness of applying multifractal analysis to conventional MR images as a new approach to detect the microstructural changes of apparently normal white matter during the early stages of atherosclerosis.

Lobar distribution of lesion volumes in late-life depression: the Biomedical Informatics Research Network (BIRN)

White matter hyperintense lesions on T2-weighted images are associated with late-life depression. Little work has been carried out examining differences in lesion location between elderly individuals with and without depression. In contrast to previous studies examining total brain white matter lesion volume, this study examined lobar differences in white matter lesion volumes derived from brain magnetic resonance imaging. This study examined 49 subjects with a DSM-IV diagnosis of major depression and 50 comparison subjects without depression. All participants were age 60 years or older. White matter lesion volumes were measured in each hemisphere using a semiautomated segmentation process and localized to lobar regions using a lobar atlas created for this sample using the imaging tools provided by the Biomedical Informatics Research Network (BIRN). The lobar lesion volumes were compared against depression status. After controlling for age and hypertension, subjects with depression exhibited significantly greater total white matter lesion volume in both hemispheres and in both frontal lobes than did control subjects. Although a similar trend was observed in the parietal lobes, the difference did not reach a level of statistical significance. Models of the temporal and occipital lobes were not statistically significant. Older individuals with depression have greater white matter disease than healthy controls, predominantly in the frontal lobes. These changes are thought to disrupt neural circuits involved in mood regulation, thus increasing the risk of developing depression.

Cognitive function in late life depression: relationships to depression severity, cerebrovascular risk factors and processing speed

BACKGROUND

A number of studies have examined clinical factors linked to worse neuropsychological performance in late life depression (LLD). To understand the influence of LLD on cognition, it is important to determine if deficits in a number of cognitive domains are relatively independent, or mediated by depression- related deficits in a basic domain such as processing speed.

METHODS

Patients who met DSM-IV criteria for major depression (n = 155) were administered a comprehensive neuropsychological battery of tasks grouped into episodic memory, language, working memory, executive function, and processing speed domains. Multiple regression analyses were conducted to determine contributions of predictor variables to cognitive domains.

RESULTS

Age, depression severity, education, race and vascular risk factors all made significant and independent contributions to one or more domains of cognitive function, with all five making independent contributions to processing speed. Age of onset made no independent contribution, after accounting for age and vascular risk factors. Of the five cognitive domains investigated, changes in processing speed were found to most fully mediate the influence of predictor variables on all other cognitive domains.

CONCLUSIONS

While slowed processing speed appears to be the most core cognitive deficit in LLD, it was closely followed by executive function as a core cognitive deficit. Future research is needed to help clarify mechanisms leading to LLD- related changes in processing speed, including the potential role of white matter abnormalities.

Frontal signal hyperintensities in mania in old age

OBJECTIVE

Signal hyperintensities (SH) on magnetic resonance (MR) imaging have been associated with increased age and with mood disorders. Frontal and subcortical neuropathology has been implicated in the pathophysiology of mania and bipolar disorders. The authors assessed frontal and subcortical SH in elderly bipolar manic patients and the comparison group, and hypothesized that SH scores would be greater in the patient group.

METHOD

MR imaging was performed in patients aged > or = 60 years with bipolar disorder, mania, and in a same-aged community comparison group. SH were rated blindly using the Boyko system. Frontal deep white matter and basal ganglia SH were assessed in the left and right hemispheres.

RESULTS

SH scores were significantly greater in patients (N = 40) than the comparison group (N = 15) in frontal deep white matter (left: p = 0.003; right: p = 0.023) based on Mann-Whitney two-sample exact tests. The SH scores in the subcortical gray regions overlapped in these groups. In patients, higher right frontal SH scores were associated with later age at onset of mania.

CONCLUSIONS

Frontal deep white matter SH may be increased in elders with bipolar disorder. Further study of the relationship of SH to age at onset in elders is warranted.

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.

Memory impairment in patients with late-onset major depression: the effect of antidepressant therapy

BACKGROUND

Cognitive deficits have been described in patients with major depression (MD), although many aspects remain unsettled.

METHOD

During an episode of MD and after remission we used tasks exploring attention, implicit, anterograde and retrograde memory to investigate 48 drug-free patients aged over 50 years without dementia, comparing them with 15 normal volunteer controls (NC). We also evaluated the effect of antidepressant therapy (ADT) with fluoxetine (F) or reboxetine (R) at baseline (T0) and six months later (T6).

RESULTS

42 patients completed the study and 6 dropped out; 33 patients were considered "Remitters" (RP) (17 F pts and 16 R pts). At T0, the entire group of MD patients (MDP) had worse performances than NC in Mini Mental Status Examination (MMSE), Wechsler Memory Scale (WMS) total score (TS), in a few subtests of WMS and in autobiographical memory. RP at T0 had the same impaired tasks and at T6 had significantly improved in MMSE, WMS. TS and many memory tests but they still differed from NC in a few complex tasks requiring more cognitive effort.

LIMITATIONS

The effects and differences between F and R must be viewed with caution considering the relatively small sample; only attention and memory were investigated.

CONCLUSIONS

Our findings confirm a negative effect of depression on memory with a significant but incomplete improvement after remission and without differences between F and R. We speculate that both a "state" and a "trait" depressive component underlie this memory impairment.

Course and outcomes of depression in the elderly

Major depressive disorder is a potentially debilitating condition that often is unrecognized or undertreated in the elderly. Even when aggressively treated, the course of geriatric depression can be severe. There is growing evidence that suggests that late-life depression may carry a higher illness burden than depression with onset earlier in life, and that severity is linked to medical and psychiatric comorbidity. Data continue to accumulate in support of various treatment modalities, including medication, electroconvulsive therapy, and psychotherapy. Given the increased risk of adverse outcomes associated with geriatric depression, such as dementia and suicide, it is essential that future investigations continue to build on the evidence base supporting improved diagnosis and treatment of this complex disorder.

Depressive symptoms and white matter changes in patients with dementia

OBJECTIVE

The aim of the present study was to investigate if depressive symptoms in demented patients are associated with white matter changes (WMCs) in the brain.

BACKGROUND

WMCs are frequently found in patients with dementia, as well as among elderly nondemented patients with depressive symptoms. However, it is less established whether or not WMCs are related to depressive symptoms in demented patients.

METHODS

67 (26 men, 41 women) patients with primary degenerative dementia (Alzheimer's disease, frontotemporal dementia), vascular dementia (VaD), or mixed Alzheimer/VaD dementia were included in the study. The patients were young-old (mean 68.1, SD 7.3). All patients underwent a standardized examination procedure and MRI of the brain. The degree of WMCs was visually rated, blindly. Depressive symptoms were rated according to the Gottfries-Bråne-Steen scale (anxiety, fear-panic, depressed mood).

RESULTS

No significant relationship was found between WMCs and depressive symptoms in the demented patients.

CONCLUSION

The possible involvement of WMCs in the pathogenesis of depressive symptoms in dementia is unclear. A link between disruptions of frontal-subcortical pathways, due to WMCs, and depressive symptomatology in dementia has been hypothesised from earlier findings, which would imply common elements of pathogenesis for depressive symptomatology and cognitive impairment in dementia. However, the results of the present study do not add further support to this hypothesis.

Depressive psychosis: clinical usefulness of MR spectroscopy data in predicting prognosis

PURPOSE

To prospectively assess the usefulness of magnetic resonance (MR) spectroscopy data acquired before the initiation of medical therapy in predicting prognosis in patients with depressive psychosis.

MATERIALS AND METHODS

All subjects gave written informed consent to an institutional committee for clinical research-approved study protocol. The clinical course after medication in 52 patients with depressive psychosis (age range, 52-78 years; 21 men, 31 women) was investigated. In all patients, MR spectroscopy was performed with a 1.5-T MR imaging unit before the initiation of medical therapy. Cerebrovascular lesions (CVLs), which appear as high-signal-intensity areas on T2-weighted MR images, were evaluated by using the Fazekas rating scale. Patients were classified into two groups on the basis of the ratio of N-acetylaspartate (NAA) to creatine and phosphocreatine (Cr): Patients in group A had an NAA/Cr ratio greater than 1.91, and patients in group B had an NAA/Cr ratio of 1.91 or less. To assess the response of the patients to medication, standard psychiatric tests--the Verbal Associative Fluency Test (VAFT), the Digit Symbol Test (DST), the Mini-Mental State Examination (MMSE), and the Hamilton Depression Rating Scale (HAM-D)--were administered before and after medical therapy was initiated. Mean test scores before and after medication were compared with paired t testing. P < .05 was considered to indicate a significant difference.

RESULTS

There were 25 patients in group A and 27 in group B. In group A, the mean VAFT and DST scores increased and the mean HAM-D score decreased after medication. There was no significant difference in mean MMSE scores before and after medication (P = .945 for group A and P = .934 for group B). In group B, there were no significant differences in any of the psychiatric test scores before and after medication. The high-signal-intensity area score in group B was significantly higher than that in group A (P = .004).

CONCLUSION

MR spectroscopy data obtained before the initiation of medical therapy were useful in predicting prognosis in patients with depressive psychosis; this suggests that the combined burden of all CVLs may affect the response to antidepressant medication.

Carotid intima-media thickness in late-onset major depressive disorder

BACKGROUND

This study explored whether patients with late-onset major depressive disorder showed higher carotid artery intima-medium thickness (IMT) and investigated the relationship between the IMT and white matter hyperintensities on magnetic resonance imaging (MRI) among patients.

METHODS

Fourteen elderly patients with late-onset major depressive disorder from a psychiatric outpatient clinic and 11 non-depressed controls received a comprehensive psychiatric assessment, ultrasound IMT measurements of the carotid arteries, and cerebral MRI.

RESULTS

The carotid IMT was higher in the patient group vs the control group (1.26 +/- 0.30 vs 1.00 +/- 0.20 mm; t = 2.40, p < 0.03). The difference was more apparent in the common carotid artery (1.20 +/- 0.32 vs 0.97 +/- 0.13 mm; t = 2.31, p < 0.04). There was a high correlation (r = 0.55, p < 0.05) between the carotid IMT and white matter hyperintensities among patients with late-onset major depressive disorder.

CONCLUSION

Results of this study suggest that atherosclerosis represented by the carotid IMT contributes to the development of late-onset major depressive disorder. The findings support the vascular depression hypothesis.

Late-life depression: the differences between early- and late-onset illness in a community-based sample

BACKGROUND

Several studies have described etiological and clinical differences between elderly depressed patients with early onset of their illness compared to late onset. While most studies have been carried out in clinical samples it is unclear whether the findings can be generalized to the elderly population as a whole. The aim of this study was to compare early-onset (EOD) and late-onset (LOD) depressive illness in a community-based sample.

METHODS

Large (n = 3107) representative sample of older persons (55-85 years) in the Netherlands. Two-stage screen procedure to identify elderly with MDD. The Center for Epidemiologic Studies Depression scale (CES-D) was used as a screen and the Diagnostic Interview Schedule (DIS) to diagnose MDD. Data on 90 older persons with early-onset depression and 39 with late-onset depression were available.

RESULTS

Those with LOD were older, and more often widowed. Family psychiatric history, vascular pathology, and stressful early and late life events did not differ between groups. EOD subjects had more often double depression and more anxiety.

CONCLUSIONS

In a community-based sample we did not detect clear differences in etiology and phenomenology between EOD and LOD. This discrepancy with reports from clinical samples could be due to selection bias in clinical studies. Consequently, all patients with late-life depression deserve a diagnostic work-up of both psychosocial and somatic risk factors and treatment interventions should be focused accordingly.

Structural abnormality on brain magnetic resonance imaging in late-onset major depressive disorder

The purpose of this study was to examine the structural abnormalities of patients with late-onset major depressive disorder using brain magnetic resonance imaging (MRI) and to assess clinical correlates of these structural abnormalities. Thirty-seven elderly patients with DSM-IV major depressive disorder that first occurred after the age of 50 years, and 18 control subjects without depression were recruited. All participants underwent comprehensive psychiatric assessment and cerebral MRI. Brain ventricular and sulcal sizes and white matter hyperintensities were assessed visually. Relative to control subjects, patients with late-life major depressive disorder showed more severe brain atrophy (p = 0.043) and white matter hyperintensities (p = 0.024), especially in the periventricular area (p = 0.012). Over 60% of the patient group had significant brain MRI hyperintensities. White matter hyperintensity was correlated with later onset of depressive illness (r = 0.49, p = 0.002) among patients. Brain atrophy and white matter hyperintensities are prevalent in patients with late-onset major depressive disorders. These two abnormalities may represent different pathophysiologic processes of depressive disorders. White matter hyperintensities may be predisposing factors for late-onset major depressive disorder.

Aging-related diagnostic variations: need for diagnostic criteria appropriate for elderly psychiatric patients

It is commonly thought and taught that most psychiatric disorders other than dementia are much less prevalent among the elderly than among younger adults. This perception is based on a relatively small number of published epidemiologic investigations of the incidence and prevalence of mental illnesses in elderly populations. Most of these studies have had a number of methodologic problems, including improper definitions and diagnostic criteria for older persons. A likely consequence of these misconceptions is that clinically significant and potentially treatable mental illnesses might be overlooked, misdiagnosed, and mistreated in elderly patients. Studies in community samples suggest that many older adults who experience clinically significant psychopathology do not fit easily into our existing nomenclature, and yet are disabled. There is a need to develop aging-appropriate diagnostic criteria for major psychiatric disorders. In this article, we discuss the potential causes of this diagnostic confusion. Four specific classes of disorders-mood (specifically depressive) disorders, schizophrenia (and related psychotic disorders), anxiety disorders, and substance use disorders-are discussed as examples. Finally, we suggest some future steps for clarifying this diagnostic confusion.

Hypofrontality and microvascular dysregulation in remitted late-onset depression assessed by functional near-infrared spectroscopy

Accumulated evidence suggests the involvement of vascular factors in late-onset depression. Late-onset depression has characteristics of poor outcome, cognitive decline, and high prevalence rather than early-onset depression. The aim of the present study was to determine whether or not the functional hypofrontality--that is, hypoperfusion and hypometabolism in the frontal lobes-seen in late-onset depression is a trait-dependent abnormality of microvascular regulation. This study was conducted on 10 patients with remitted late-onset major depressive disorder (MDD) and 10 healthy volunteers matched for vascular factors and subcortical, or white matter, hyperintensities (WMH). Using near-infrared spectroscopy combined with magnetic resonance imaging, we investigated the microvascular reactivity in the prefrontal cortex during a cognitive task and during carbon dioxide (CO(2)) inhalation. Activation of the prefrontal cortex during the cognitive task was significantly less in patients as compared with controls, although task performance was not significantly different between the two groups. In the patients, a tendency of negative correlation between the reduced prefrontal activation during a cognitive task and the severity of hyperintensity in periventricular region was observed. Vasomotor reactivity to CO(2) inhalation was significantly lower in the patients than in the controls. Although there was no significant association between the activation during the cognitive and that during the CO(2) inhalation task, the present results suggest that prefrontal microvascular dysregulation as shown by NIRS is involved in the pathophysiological basis of functional hypofrontality in late-onset depression. This finding will provide a new framework for the development of diagnostic methods, treatments, and preventive strategies against late-onset depression.

Greater MRI lesion volumes in elderly depressed subjects than in control subjects

Hyperintense lesions in both white matter and gray matter on T2-weighted magnetic resonance imaging (MRI) are associated with late-life depression. This large study examined differences in gray and white matter lesion volumes on brain MRI between 253 elderly depressed and 146 control subjects. White matter and gray matter lesion volumes were measured in each hemisphere using a semi-automated segmentation process and compared against depression status. Depressed subjects exhibited significantly greater total white matter (mean 7.22 ml) and gray matter (mean 0.30 ml) lesion volumes in both hemispheres than did control subjects (mean 4.87 ml in white matter and 0.18 ml in gray matter). This difference remained statistically significant even after controlling for confounders such as age, sex, race and reports of hypertension, diabetes and heart disease. Patients with late-life depression have larger white matter lesion and gray matter lesion volumes than do control subjects. Future research should combine similar volumetric techniques with methods of identifying the location of lesions specific to late-life depression.

White matter hyperintensities and chronicity of depression

OBJECTIVE

White matter hyperintensities (WMHs) on T(2)-weighted magnetic resonance imaging (MRI) of the brain are associated with advanced age and late-life depression. Most investigations predominantly found these lesions in frontal lobe and basal ganglia supporting the hypothesis of a fronto-striatal dysfunction in depression. A prospective study was undertaken to investigate the association between extent of WMHs and clinical outcome in elderly depressed patients.

METHODS

Thirty-one non-demented depressed subjects underwent a 1.5 T cranial MRI scan. The MRI scans were analysed in consensus by two experienced radiologists. Each MRI scan was assessed for presence and extent of WMHs, which are differentiated in periventricular hyperintensities (PVHs) and deep white matter hyperintensities (DWMHs). A total of 21 patients of the original cohort of 31 patients were re-assessed 5 years after baseline assessment. We ascertained the severity of depressive symptoms, the longitudinal course of depression, the cognitive decline and the global assessment of functioning at follow-up visit.

RESULTS

(1) Subjects with greater extent of WMHs had a significant higher Hamilton Depression Rating Scale (HAM-D) score, (2) had more severe longitudinal courses of depression (3) and had a lower Mini-Mental State Examination (MMSE) score.

CONCLUSIONS

WMHs on MRI are associated with poorer outcome in elderly depressed subjects. Further studies are needed to evaluate WHMs as prognostic factor for an appropriate treatment decision-making.

Cerebrovascular disease and late-life depression

Depression may occur as a result of vascular disease in a significant subpopulation of elderly persons. Indirect support for vascular disease as an underlying etiology of late-life depression includes the high rate of depression in patients with vascular disease, the frequency of "silent stroke" and white-matter hyperintensities in late-life depression, and the lower frequency of positive family histories of depression in such patients. The authors evaluate the associations of late-life depression with cerebrovascular disease by reviewing the existing pathophysiological, prognosis, and treatment-outcomes studies. Findings are based on review of the current literature systematically searched in electronic databases. Review of such studies indicates a high frequency of depression in older patients with cardiovascular and cerebrovascular diseases, and the possibility of a bidirectional relationship between depression and vascular disease. Studies examining patients with vascular depression have found that such patients have different symptom profiles, greater disability, and higher risk for poorer outcomes than those with nonvascular depression. Since the vascular depression hypothesis was proposed as a conceptual framework, evidence has accumulated that patients with vascular depression may have poorer outcomes that may be related in part to executive dysfunction and consequent disability. However, the association of vascular risk factors with geriatric depression has not been consistent in the studies to-date. Although an association between a subset of late-life depression and vascular disease is clear, significant gaps remain in our understanding. Further research is needed to establish the precise linkages and interactions between vascular disease and geriatric depression.

Serum cholesterol and cognitive performance in the Framingham Heart Study

OBJECTIVE

The objective of this study was to examine the relationship between total cholesterol (TC) and cognitive performance within the context of the Framingham Heart Study, a large, community-based, prospective investigation of cardiovascular risk factors.

METHODS

Participants were 789 men and 1105 women from the Framingham Heart Study original cohort who were free of dementia and stroke and who received biennial TC determinations over a 16- to 18-year surveillance period. Cognitive tests were administered 4 to 6 years subsequent to the surveillance period and consisted of measures of learning, memory, attention/concentration, abstract reasoning, concept formation, and organizational abilities. Statistical models were adjusted for multiple demographic and biological covariates.

RESULTS

There was a significant positive linear association between TC and measures of verbal fluency, attention/concentration, abstract reasoning, and a composite score measuring multiple cognitive domains. Performance levels for three clinically defined groups were examined. Participants with "desirable" TC levels (<200 mg/dL) performed less well than participants with borderline-high TC levels (200-239 mg/dL) and participants with high TC levels (there exists 240 mg/dL).

CONCLUSIONS

Lower naturally occurring TC levels are associated with poorer performance on cognitive measures, which place high demands on abstract reasoning, attention/concentration, word fluency, and executive functioning.

Is vascular depression a distinct sub-type of depressive disorder? A review of causal evidence

BACKGROUND

Vascular depression is an important conceptual and clinical concept.

OBJECTIVE

To apply criteria which, in an ideal world, should be satisfied before an association between depression and vascular disease can be considered robust.

METHOD

A literature review with discussion of findings in the light of recently suggested guidelines for the development of new psychiatric disorders.

RESULTS

There is considerable evidence linking depression in later life with vascular brain disease but the interaction is bi-directional. Depression and vascular disease could be mediated by factors other than traditional vascular risk factors. There is increasing interest in mechanisms such as inflammatory processes which may mediate both depression and vascular disease.

CONCLUSIONS

Vascular depression provides a useful framework with which to remind the clinician of important interactions between depression and vascular disease but conceptually it may be too restrictive.

Hippocampal changes and white matter lesions in early-onset depression

BACKGROUND

Hippocampal volume reduction and increased prevalence of subcortical white matter lesions have been reported in late-life depression. We aimed to examine whether total number of subcortical white matter lesions were associated with reduced hippocampal volume in aged female subjects with early-onset depression (< 45 years) and healthy comparison subjects.

METHODS

The study included 28 middle-aged and elderly subjects with major depression and 41 age-matched control subjects. Hippocampal, parahippocampal gyrus, and orbitofrontal cortex volumes were determined using manual tracing methods. White matter lesions were rated from T2-weighted MRI scans using a semiquantitative classification scale.

RESULTS

After controlling for total brain volume and age, patients had reduced hippocampal volume due to right hippocampal volume decrease (2.84 mL vs. 3.12 mL, F = 16.6, p < .001). Parahippocampal and orbitofrontal volumes did not differ significantly between groups. Multiple linear regression analysis indicated that reduced hippocampal volume did not significantly correlate with total number of subcortical white matter lesions (t = .673, p = .518).

CONCLUSIONS

Right hippocampal volume was reduced in aged female early-onset subjects with depression. Total number of subcortical white matter lesions was not associated with the decrease in right hippocampal volume. Our data suggest hippocampal involvement, independent of subcortical white matter lesions, in the neuropathology of early-onset depression.

Cerebral white matter lesions and hypertension status in the elderly Korean: the Ansan Study

There is evidence of an association of hypertension with white matter lesions (WMLs), leukoaraiosis, in the human brain in the United States, Europe and Japan. However, no study on this association has been reported in Korea. Community-dwelling elderly subjects aged over 61 years were randomly selected from samples of the Ansan Health Study, while their blood pressures (BPs) were measured using a highly standardized protocol. Hypertension was defined as a systolic BP> or =140 mmHg or a diastolic BP> or =90 mmHg or as reported treatment with hypertensive medication, and further subclassified with respect to its subtypes and control status. WMLs were determined by a 1.5-T MRI scan and further categorized into five subgroups with respect to its severity. Hypertension status, such as uncontrolled hypertension even after antihypertensive medication (adjusted odd ratio [OR]=6.07; 95% CI, 2.08-17.78), isolated systolic hypertension before medication (OR=2.66; 95% CI, 1.08-6.57), and hypertension before medication (OR=2.55; 95% CI, 1.19-5.46) were significantly and independently correlated with the presence and severity of WMLs. Advancing age (OR=1.76; 95% CI, 1.38-2.25), lacunar infarction (OR=3.19; 95% CI, 1.83-5.58), and cigarette smoking (OR=1.10; 95% CI, 1.03-1.18) were significantly related to the presence and severity of WMLs. Regular and tight control for hypertension should be exercised to prevent WMLs among the elderly with hypertension.

Neurocognitive profiles in elderly patients with frontotemporal degeneration or major depressive disorder

Major depressive disorder (MDD) and frontotemporal dementia (FTD) are both disorders in elderly populations that involve the prefrontal cortex and appear to have similar neurocognitive deficits. This review examined whether there are testable deficits in cognition that are consistent across individuals within the same neuropathological condition that could be used to facilitate early diagnoses. Medline and PsychInfo databases were searched for cognitive studies of depressed and FTD patients that used a matched control group and reported findings with means and standard deviations (N = 312). Effect sizes for FTD patients with mild and moderately advanced disease were compared to effect sizes within subgroups of depressed patients, such as inpatients, outpatients and community volunteers. Moderately advanced FTD patients were more impaired than depressed patients over all domains, particularly in language ability, although depressed inpatients appeared similar to FTD patients in some domains. Effect sizes for FTD patients who were in the mild, or early, stage of the disease (MMSE = 28) were similar to those of depressed outpatients but slightly worse than those of community volunteers in all domains except semantic memory and executive ability. In the latter two domains, even mild FTD patients had notably large deficits. All FTD patients showed more severe deficits in some domains relative to other domains. In contrast, depressed patients tended to vary by clinical presentation or disease severity, but the magnitude of impairment for each subgroup remained relatively consistent across domains and they did not have the severe focal deficits in one or two domains demonstrated by FTD patients.

Neuroanatomical localisation and clinical correlates of white matter lesions in the elderly

BACKGROUND

White matter lesions (WML) in elderly people co-occur with hypertension, depression, and cognitive impairment. Little is known about the density and distribution of WML in normal elderly people, whether they occur randomly in the aging brain or tend to cluster in certain areas, or whether patterns of WML aggregation are linked to clinical symptoms.

OBJECTIVES

To describe patterns of WML distribution in a large representative population of elderly people using non-inferential cluster analysis; and to determine the extent to which such patterns are associated with clinical symptomatology.

METHOD

A population sample of 1077 elderly people was recruited. Multiple analysis of correspondence followed by automatic classification methods was used to explore overall patterns of WML distribution. Correspondence was then sought between these patterns and a range of cerebrovascular, psychiatric, and neurological symptoms.

RESULTS

Three distinct patterns of spatial localisation within the brain were observed, corresponding to distinct clusters of clinical symptoms. In particular WML aggregation in temporal and occipital areas was associated with greater age, hypertension, late onset depressive disorder, poor global cognitive function, and overall WML frequency.

CONCLUSIONS

WML localisation is not random in the aging brain, and their distribution is associated with age and the presence of clinical symptoms. Age differences suggest there may be patterns of progression across time; however, this requires confirmation from longitudinal imaging studies.

Carotid sinus syndrome is common in dementia with Lewy bodies and correlates with deep white matter lesions

BACKGROUND

Carotid sinus syndrome (CSS) is a common cause of syncope in older persons. There appears to be a high prevalence of carotid sinus hypersensitivity (CSH) in patients with dementia with Lewy bodies (DLB) but not in Alzheimer's disease.

OBJECTIVE

To compare the prevalence of CSH in DLB and Alzheimer's disease, and to determine whether there is an association between CSH induced hypotension and brain white matter hyperintensities on magnetic resonance imaging (MRI).

METHODS

Prevalence of CSH was compared in 38 patients with DLB (mean (SD) age, 76 (7) years), 52 with Alzheimer's disease (80 (6) years), and 31 case controls (73 (5) years) during right sided supine carotid sinus massage (CSM). CSH was defined as cardioinhibitory (CICSH; >3 s asystole) or vasodepressor (VDCSH; >30 mm Hg fall in systolic blood pressure (SBP)). T2 weighted brain MRI was done in 45 patients (23 DLB, 22 Alzheimer). Hyperintensities were rated by the Scheltens scale.

RESULTS

Overall heart rate response to CSM was slower (RR interval = 3370 ms (640 to 9400)) and the proportion of patients with CICSH greater (32%) in DLB than in Alzheimer's disease (1570 (720 to 7800); 11.1%) or controls (1600 (720 to 3300); 3.2%) (p<0.01)). The strongest predictor of heart rate slowing and CSH was a diagnosis of DLB (Wald 8.0, p<0.005). The fall in SBP during carotid sinus massage was greater with DLB (40 (22) mm Hg) than with Alzheimer's disease (30 (19) mm Hg) or controls (24 (19) mm Hg) (both p<0.02). Deep white matter hyperintensities were present in 29 patients (64%). In DLB, there was a correlation between magnitude of fall in SBP during CSM and severity of deep white matter changes (R = 0.58, p = 0.005).

CONCLUSIONS

Heart rate responses to CSM are prolonged in patients with DLB, causing hypotension. Deep white matter changes from microvascular disease correlated with the fall in SBP. Microvascular pathology is a key substrate of cognitive impairment and could be reversible in DLB where there are exaggerated heart rate responses to carotid sinus stimulation.

Hippocampal volume change in depression: late- and early-onset illness compared

BACKGROUND

Evidence for structural hippocampal change in depression is limited despite reports of neuronal damage due to hypercortisolaemia and vascular pathology.

AIMS

To compare hippocampal and white matter structural change in demographically matched controls and participants with early-onset and late-onset depression.

METHOD

High-resolution volumetric magnetic resonance imaging (MRI) and rating of MRI hyperintensities.

RESULTS

A total of 51 people with depression and 39 control participants were included. Participants with late-onset depression had bilateral hippocampal atrophy compared with those with early-onset depression and controls. Hippocampal volumes did not differ between control participants and those with early-onset depression. Age of depression onset correlated (negatively) with hippocampal volume but lifetime duration of depression did not. Hyperintensity ratings did not differ between groups.

CONCLUSIONS

Results suggest that acquired biological factors are of greater importance in late-than in early-onset illness and that pathological processes other than exposure to hypercortisolaemia of depression underlie hippocampal atrophy in depression of late life.

Do severity and duration of depressive symptoms predict cognitive decline in older persons? Results of the Longitudinal Aging Study Amsterdam

BACKGROUND AND AIMS

Some prospective studies show that depression is a risk factor for cognitive decline. So far, the explanation for the background of this association has remained unclear. The present study investigated 1) whether depression is etiologically linked to cognitive decline; 2) whether depression and cognitive decline may be the consequence of the same underlying subcortical pathology, or 3) whether depression is a reaction to global cognitive deterioration.

METHODS

A cohort of 133 depressed and 144 non-depressed older persons was followed at eight successive observations over 3 years. All subjects were participants in the Longitudinal Aging Study Amsterdam (LASA). Depression symptoms were measured by means of the CES-D at eight successive waves. Cognitive function (memory function, information processing speed, global cognitive functioning) was assessed at baseline and at the last CES-D measurement.

RESULTS

The severity and duration of depressive symptoms were not associated with subsequent decline in memory functioning or global cognitive decline. There was an association between both chronic mild depression and chronic depression, and decline in speed of information processing.

CONCLUSIONS

These results support the hypothesis that, in older persons, chronic depression as well as cognitive decline may be the consequence of the same underlying subcortical pathology.

Late onset dysthymic disorder and major depression differ from early onset dysthymic disorder and major depression in elderly outpatients

BACKGROUND

Age of onset may affect clinical features and prognosis in elderly patients with major depression (MDD), but there is a lack of such data in elderly patients with dysthymic disorder (DD) and systematic comparisons of late onset MDD and DD have not been conducted.

METHODS

In a Late Life Depression Clinic, patients > or = 60 years old who met DSM-III-R or DSM-IV criteria for MDD or DD were studied. The 24-item Hamilton Rating Scale for Depression (HRSD) and SCID-P were completed, family history was obtained, and medical illnesses were assessed.

RESULTS

In the total sample (n=370; 211 MDD and 159 DD), compared to early onset patients, late onset (onset > or =60 years) patients had a higher rate of cardiovascular disease (chi(2)=4.12, df=1, P<0.05), lower rate of anxiety disorder (chi(2)=4.19, df=1, P<0.05), and a lower rate of family history of affective disorder (chi(2)=9.37, df=1, P<0.002). Late onset DD patients were more likely to have cardiovascular disease than early onset DD patients (chi(2)=5.63, df=1, P<0.02), but the rate of cardiovascular disease did not differ between late and early onset MDD patients (chi(2)=0.35, df=1, P<0.6). Late onset MDD patients were less likely to have a family history of affective disorder than early onset MDD patients (chi(2)=10.71, df=1, P<0.001). Prevalence of anxiety disorders did not differ between the early and late onset MDD patients (chi(2)=0.07, df=1, P<0.79), but was more common in the early onset DD compared to the late onset DD patients (17.98% versus 4.29%, chi(2)=6.98, df=1, P<0.01). Late onset DD did not differ from late onset MDD in the rates of cardiovascular disease, anxiety disorders, and family history of affective disorder. Excluding patients with double depression (n=32) did not alter the cardiovascular or family history findings, but the difference in anxiety disorders between early and late onset DD patients was no longer significant.

LIMITATIONS

Academic clinic sample results may not generalize to community populations.

CONCLUSIONS

In the elderly, late-onset DD is typically different from early onset DD. Cerebrovascular disease appears to play a role in the etiology of late onset DD. The similarities between late onset DD and late onset MDD suggest a single condition along a continuum.

Clinical characteristics of magnetic resonance imaging-defined subcortical ischemic depression

BACKGROUND

There is a substantial body of research supporting the vascular depression hypothesis of late-life depression. To update this hypothesis so it incorporates recent research, we propose that the term subcortical ischemic vascular depression may be a more accurate representation of the disease process. We sought to investigate this diagnosis as a construct by examining differences between depressed subjects with and without magnetic resonance imaging defined subcortical ischemic vascular depression.

METHODS

This case-control study examined 139 depressed elderly subjects. Demographic data, psychiatric, medical, and family history, depressive symptomatology, and functional impairment were compared between groups dichotomized based on neuroimaging findings.

RESULTS

Seventy-five (54%) of the subjects met neuroimaging criteria for subcortical ischemic vascular depression. Age was most strongly associated with increased prevalence of subcortical ischemic vascular depression. Lassitude and a history of hypertension were also positively associated with the diagnosis; a family history of mental illness and loss of libido were negatively associated with the diagnosis.

CONCLUSIONS

These data support that subcortical ischemic vascular depression may be a specific syndrome from other types of late-life depression. Further research is needed to further characterize this disorder, particularly in regards to cognitive function and treatment implications.

Unipolar late-onset depression: A comprehensive review

Background

The older population increases all over the world and so also does the number of older psychiatric patients, which manifest certain specific and unique characteristics. The aim of this article is to provide a comprehensive review of the international literature on unipolar depression with onset at old age.

Methods

The authors reviewed several pages and books relevent to the subject but did not search the entire literature because of it's overwhelming size. They chose to review those considered most significant.

Results

The prevalence of major depression is estimated to be 2% in the general population over 65 years of age. The clinical picture of geriatric depression differs in many aspects from depression in younger patients. It is not yet clear whether it also varies across cultures and different socio-economic backgrounds. Biological data suggest that it is associated with an increased severity of subcortical vascular disease and greater impairment of cognitive performance. Many authors consider the existence of a somatic disorder to be related to the presence of depression in late life, even constituting a negative prognostic factor for the outcome of depression. Most studies support the opinion that geriatric depression carries a poorer prognosis than depression in younger patients. The therapeutic intervention includes pharmacotherapy, mainly with antidepressants, which is of established value and psychotherapy which is not equally validated.

Conclusion

A significant number of questions regarding the assessment and treatment of geriatric depression remain unanswered, empirical data are limited, and further research is necessary.