The association of antidepressant drug usage with cognitive impairment or dementia, including Alzheimer disease: A systematic review and meta-analysis

Psilocybin for dementia prevention? The potential role of psilocybin to alter mechanisms associated with major depression and neurodegenerative diseases

Major depression is an established risk factor for subsequent dementia, and depression in late life may also represent a prodromal state of dementia. Considering current challenges in the clinical development of disease modifying therapies for dementia, the focus of research is shifting towards prevention and modification of risk factors to alter the neurodegenerative disease trajectory. Understanding mechanistic commonalities underlying affective symptoms and cognitive decline may reveal biomarkers to aid early identification of those at risk of progressing to dementia during the preclinical phase of disease, thus allowing for timely intervention. Adult hippocampal neurogenesis (AHN) is a phenomenon that describes the birth of new neurons in the dentate gyrus throughout life and it is associated with spatial learning, memory and mood regulation. Microglia are innate immune system macrophages in the central nervous system that carefully regulate AHN via multiple mechanisms. Disruption in AHN is associated with both dementia and major depression and microgliosis is a hallmark of several neurodegenerative diseases. Emerging evidence suggests that psychedelics promote neuroplasticity, including neurogenesis, and may also be immunomodulatory. In this context, psilocybin, a serotonergic agonist with rapid-acting antidepressant properties has the potential to ameliorate intersecting pathophysiological processes relevant for both major depression and neurodegenerative diseases. In this narrative review, we focus on the evidence base for the effects of psilocybin on adult hippocampal neurogenesis and microglial form and function; which may suggest that psilocybin has the potential to modulate multiple mechanisms of action, and may have implications in altering the progression from major depression to dementia in those at risk.

Central nervous system medication use around hospitalization

BACKGROUND

Central nervous system (CNS) medication use is common among older adults, yet the impact of hospitalizations on use remains unclear. This study details CNS medication use, discontinuations, and user profiles during hospitalization periods.

METHODS

Retrospective cohort study using electronic health records on patients ≥65 years, from three hospitals (2018-2020), and prescribed a CNS medication around hospitalization (90 days prior to 90 days after). Latent class transitions analysis (LCTA) examined profiles of CNS medication class users across four time points (90 days prior, admission, discharge, 90 days after hospitalization).

RESULTS

Among 4666 patients (mean age 74.3 ± 9.3 years; 63% female; 70% White; mean length of stay 4.6 ± 5.6 days (median 3.0 [2.0, 6.0]), the most commonly prescribed CNS medications were antidepressants (56%) and opioids (49%). Overall, 74% (n = 3446) of patients were persistent users of a CNS medication across all four time points; 7% (n = 388) had discontinuations during hospitalization, but of these, 64% (216/388) had new starts or restarts within 90 days after hospitalization. LCTA identified three profile groups: (1) low CNS medication users, 54%-60% of patients; (2) mental health medication users, 30%-36%; and (3) acute/chronic pain medication users, 9%-10%. Probability of staying in same group across the four time points was high (0.88-1.00). Transitioning to the low CNS medication use group was highest from admission to discharge (probability of 9% for pain medication users, 5% for mental health medication users). Female gender increased (OR 2.4, 95% CI 1.3-4.3), while chronic kidney disease lowered (OR 0.5, 0.2-0.9) the odds of transitioning to the low CNS medication use profile between admission and discharge.

CONCLUSIONS

CNS medication use stays consistent around hospitalization, with discontinuation more likely between admission and discharge, especially among pain medication users. Further research on patient outcomes is needed to understand the benefits and harms of hospital deprescribing, particularly for medications requiring gradual tapering.

Association between Depressive Mood, Antidepressant Therapy and Neuropsychological Performances: Results from a Cross-Sectional Study on Elderly Patients

BACKGROUND

Currently, the global demographic landscape is undergoing a transformative shift towards an increasingly aging population. This leads to an increase in chronic pathologies, including depression and cognitive impairment. This study aimed to evaluate the association between depressive mood, whether in treatment or not, and cognitive capacities, assessed using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS).

METHODS

This study included 259 subjects, aged 65 years or older, evaluated at the Geriatric Outpatient Service of the University Hospital of Monserrato, Cagliari, between July 2018 and May 2022, who experienced subjective depressive mood and/or cognitive deficits.

RESULTS

Only 25.1% of the sample showed no cognitive impairment on the RBANS. Education was a significant regressor of the RBANS Total Scale scores (p < 0.0001) and was negatively associated with mood deflection (r = -0.15, p = 0.0161). Subjects with depressive mood had more impaired attention and visuospatial/constructional abilities compared to untreated euthymic patients. Post-hoc analysis, conducted with the Conover test, showed that untreated euthymic patients (GDS-15 ≤ 5, group 2) had a higher score on the RBANS total scale than patients with mood deflection (GDS-15 > 5, group 1), and treated euthymic patients (GDS-15 ≤ 5, group 3). Finally, different logistic regression analyses revealed a significant negative coefficient for GDS as a regressor of the RBANS total scale (coefficient: -0.04, p = 0.0089), visuospatial/constructional abilities (coefficient: -0.03, p = 0.0009), language (coefficient: -0.05, p = 0.0140), and attention (coefficient: -0.05, p < 0.0001).

CONCLUSIONS

Our analysis demonstrated that "naturally" euthymic people show better cognitive performances than people with depressive mood and subjects with acceptable mood due to antidepressants. Furthermore, the gender-based difference observed in the language domain suggests the potential utility of incorporating an alternative category for male patients in the Semantic Fluency test.

Dual-Task Zumba Gold for Improving the Cognition of People With Mild Cognitive Impairment: A Pilot Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

Integrating mental activities with physical exercises (e.g., dual-tasking) may potentially improve cognition in older adults and people with mild cognitive impairment (MCI). This study investigated the preliminary efficacy of a new intervention called dual-task Zumba Gold (DTZ) on people with MCI to guide an adequately-powered full-scale trial.

RESEARCH DESIGN AND METHODS

This is a 2-arm pilot randomized controlled trial with 60 people with MCI assigned to a 12-week DTZ intervention or control group (health education). We hypothesized that DTZ would facilitate significant improvements in global cognition (primary outcome) and other psychological/physical measures at postintervention (T1) and 6-week follow-up (T2). Generalized estimating equations with an intention-to-treat approach were used to evaluate intervention effects. Postintervention qualitative interviews explored the participants' program perceptions.

RESULTS

Fifty-one participants completed the study, with no adverse events reported. DTZ participants showed significant improvements in global cognition (p < .001, d = 0.75-0.78), executive function (p < .001, d = 0.28-0.33), immediate recall (p < .001, d = 0.50-0.54), delayed recall (p = .003, d = 0.66-0.71), quality of life (p = .027, d = 0.59-0.63), and mobility (p = .005, d = 0.53-0.56) at T1 and T2. There were nonsignificant changes in working memory, depressive symptoms, blood pressure, body mass index, and waist circumference. Participants conveyed intervention acceptability, including challenges/barriers, enablers, and future recommendations.

DISCUSSION AND IMPLICATIONS

DTZ is a potentially feasible intervention for people with MCI that may improve cognition, quality of life, and mobility. A full-scale trial is recommended for confirmatory evaluation.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04788238.

The cognitive effects of adjunctive repetitive transcranial magnetic stimulation for late-onset depression: a randomized controlled trial with 4 week follow-up

Objectives

Cognitive impairment is common and linked to poor outcomes in patients with late-onset depression (LOD). The cognitive effects of repetitive transcranial magnetic stimulation (rTMS) for LOD are not well understood. This study aimed to investigate the effects of rTMS on cognitive function in elderly patients with LOD.

Methods

In total, 58 elderly patients (aged 60 to 75 years) with depression were enrolled and randomly assigned to an active rTMS group or a sham group. The participants received active or sham rTMS over the left dorsolateral prefrontal cortex for 4 weeks, 5 days a week, at a frequency of 10 Hz rTMS and 120% of the motor threshold (MT). Cognitive function was assessed using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) at baseline, the end of the 4 week treatment period, and at the 4 week follow-up.

Results

The active rTMS group showed significant improvements in immediate memory and attention scores on the RBANS compared to the sham group. However, no significant differences were observed between the two groups in other cognitive domains assessed by the RBANS. No serious adverse events related to rTMS treatment were observed.

Conclusion

Treatment with 120% MT rTMS was associated with improvement in cognitive defects related to the active phase of LOD. These findings suggest that rTMS could provide early improvements in cognitive function in clinical settings for elderly patients with LOD.Clinical trial registration: https://www.chictr.org.cn/showproj.html?proj=40698, identifier ChiCTR1900024445.

Percutaneous electrical nerve field stimulation improves comorbidities in children with cyclic vomiting syndrome

Introduction

Children with cyclic vomiting syndrome (CVS) frequently suffer from disabling abdominal pain and comorbidities that impair quality of life. A noninvasive, auricular percutaneous electrical nerve field stimulation (PENFS) device is shown to be effective for abdominal pain in children with disorders of gut-brain interaction. We aimed to determine the effects of PENFS on pain, common comorbidities, and quality of life in pediatric CVS.

Methods

Children aged 8-18 years with drug-refractory CVS were enrolled in a prospective, open-label study receiving 6 consecutive weeks of PENFS. Subjects completed the following surveys at baseline, during/after therapy (week 6), and at extended follow-up approximately 4-6 months later: Abdominal Pain Index (API), State-Trait Anxiety Inventory for Children (STAI-C), Pittsburgh Sleep Quality Index (PSQI), and Patient Reported Outcome Measurement Information System (PROMIS) Pediatric Profile-37.

Results

Thirty subjects were included. Median (interquartile range, IQR) age was 10.5 (8.5-15.5) years; 60% were female. Median API scores decreased from baseline to week 6 (p = 0.003) and to extended follow-up (p < 0.0001). State anxiety scores decreased from baseline to week 6 (p < 0.0001) and to extended follow-up (p < 0.0001). There were short-term improvements in sleep at 6 weeks (p = 0.031) but not at extended follow-up (p = 0.22). Quality of life measures of physical function, anxiety, fatigue, and pain interference improved short-term, while there were long-term benefits for anxiety. No serious side effects were reported.

Conclusions

This is the first study to demonstrate the efficacy of auricular neurostimulation using PENFS for pain and several disabling comorbidities in pediatric CVS. PENFS improves anxiety, sleep, and several aspects of quality of life with long-term benefits for anxiety.Clinical trial registration: ClinicalTrials.gov, identifier NCT03434652.

Mindfulness-based stress reduction for community-dwelling older adults with subjective cognitive decline (SCD) and mild cognitive impairment (MCI) in primary care: a mixed-methods feasibility randomized control trial

BACKGROUND

Primary care is often the first point of contact when community-dwelling older adults experience subjective cognitive decline (SCD) or mild cognitive impairment (MCI). Living with SCD or MCI can be life-altering, resulting in low mood and increased anxiety, further exacerbating cognitive decline. However, there is scant literature on interventions that interprofessional primary care providers can provide to support those living with SCD or MCI. Practicing mindfulness-based stress reduction (MBSR) in an interprofessional primary care setting may support emotional health and well-being for those with cognitive decline, but it has not been studied in an interprofessional primary care context.

OBJECTIVES

This study's primary aim was to determine the feasibility of, and perceived benefits to and satisfaction with, a 9-Week MBSR program delivered in a team-based primary care setting. The secondary aim was to examine the acceptability of using technology (computer tablet and App Insight Timer®) for program delivery and home practice.

METHODS

A convergent mixed-methods, single-blind pilot randomized controlled trial (RCT) study design was used. A quantitative strand was used to evaluate the feasibility of the MBSR program. The qualitative strand used a focus group with older adult participants with SCD or MCI. Individual semi-structured interviews with occupational therapists who are qualified-MBSR teachers were conducted to explore the acceptability of using computer tablets for program delivery and home practice.

RESULTS

27 participants were randomized (14 MBSR; 13 Control) with retention rates of 64.3% (9/14 completed ≥6 sessions), true adherence rates of 50% (7/14 met ≥19.5 hrs of home practice), 21.4% attrition rates, and 100% post-intervention follow-up. No participants who used computer tablets at the beginning of the intervention switched to low technology. Older adult participants found the use of computer tablets in the MBSR course acceptable and appreciated the portability of the tablets.

CONCLUSIONS

Based on the lower-than-expected rates of recruitment, retention, and adherence, our study, as designed, did not meet the feasibility benchmarks that were set. However, with minor modifications to the design, including changing how participants who drop-out are analyzed, extending recruitment, and adding multiple sites, this intervention would be well suited to further study using a full-scale RCT. However, we found that embedding MBSR in an interprofessional primary care setting was feasible in practice and qualitative data highlighted the satisfaction and perceived benefits based on the intervention. The use of technology was acceptable and portable, as participants utilized their computer tablets consistently until the study's end. Our study showed that older adults living with SCD or MCI were highly receptive to learning how to use technology, and future group intervention programs in interprofessional primary care settings may also incorporate tablet use.

TRIAL REGISTRATION

This study was reviewed and approved by the Research Ethics Board in Toronto, Ontario, Canada (REB# 2017-0056-E); Queen's University (REB# 6026418) in Kingston, Ontario, Canada, and Clinicaltrials.gov (08/03/2019; NCT03867474).

Dementia risk predictions from German claims data using methods of machine learning

INTRODUCTION

We examined whether German claims data are suitable for dementia risk prediction, how machine learning (ML) compares to classical regression, and what the important predictors for dementia risk are.

METHODS

We analyzed data from the largest German health insurance company, including 117,895 dementia-free people age 65+. Follow-up was 10 years. Predictors were: 23 age-related diseases, 212 medical prescriptions, 87 surgery codes, as well as age and sex. Statistical methods included logistic regression (LR), gradient boosting (GBM), and random forests (RFs).

RESULTS

Discriminatory power was moderate for LR (C-statistic = 0.714; 95% confidence interval [CI] = 0.708-0.720) and GBM (C-statistic = 0.707; 95% CI  = 0.700-0.713) and lower for RF (C-statistic = 0.636; 95% CI  = 0.628-0.643). GBM had the best model calibration. We identified antipsychotic medications and cerebrovascular disease but also a less-established specific antibacterial medical prescription as important predictors.

DISCUSSION

Our models from German claims data have acceptable accuracy and may provide cost-effective decision support for early dementia screening.

Preparation of β-lactoglobulin-derived tryptophan peptide and its effect on anxiety-like behaviors in Zebrafish

This study aimed to obtain three Trp-containing peptides from β-lactoglobulin and study their effects on anxiety-like behaviors in zebrafish. Three Trp-containing peptides were prepared from β-lactoglobulin by selective enzymatic hydrolysis and identified by UPLC-Q-TOF MS/MS. The anxiety-like behaviors of zebrafish were reduced after two weeks of administrated of β-lactoglobulin Trp peptides (LAWP), VAGTWY, VAGTW and G TW(concentration of 56 μg/mL or 500 μg/mL). As an index of serotonergic activity, we assessed the enhancing abilities of 5-HT synthesis. The treatment remarkably enhanced the 5-HT synthesis by upregulation of Trp concentration and Trp hydroxylase activation. In addition, this study further validated the anti-anxiety effects of whey protein hydrolysate with a high Trp index in animal and the experimental results were consistent with those reported in previous studies. Our results showed that β-lactoglobulin Trp peptides ingestion has a significant anti-anxiety effect as evidenced by the increasing Trp concentration, TPH activation and 5-HT level compared to the control group, with the VAGTW being the more effective.

Altered topological properties of functional brain networks in patients with first episode, late-life depression before and after antidepressant treatment

Objectives

To preliminarily explore the functional activity and information integration of the brains under resting state based on graph theory in patients with first-episode, late-life depression (LLD) before and after antidepressant treatment.

Methods

A total of 50 patients with first-episode LLD and 40 non-depressed controls (NCs) were recruited for the present research. Participants underwent the RBANS test, the 17-item Hamilton depression rating scale (HAMD-17) test, and resting-state functional MRI scans (rs-fMRI). The RBANS test consists of 12 sub-tests that contribute to a total score and index scores across the five domains: immediate memory, visuospatial/constructional, language, attention, and delayed memory. Escitalopram or sertraline was adopted for treating depression, and the dosage of the drug was adjusted by the experienced psychiatrists. Of the 50 LLD patients, 27 cases who completed 6-month follow-ups and 27 NCs matched with age, sex, and education level were included for the final statistical analysis.

Results

There were significant differences in RBANS total score, immediate memory, visuospatial/constructional, language, attention, and delayed memory between LLD baseline group and NCs group (P < 0.05). Considering the global attribute indicators, the clustering coefficient of global indicators was lower in the LLD baseline group than in the NCs group, and the small-world attribute of functional brain networks existed in all three groups. The degree centrality and node efficiency of some brains were lower in the LLD baseline group than in the NCs group. After 6 months of antidepressant therapy, the scores of HAMD-17, immediate memory, language, and delayed memory in the LLD follow-up group were higher than those in the LLD baseline group. Compared with the LLD baseline group, the degree centrality and node efficiency of some brains in the cognitive control network were decreased in the LLD follow-up group.

Conclusions

The ability to integrate and divide labor of functional brain networks declines in LLD patients and linked with the depression severity. After the relief of depressive symptoms, the small-world attribute of functional brain networks in LLD patients persists. However, the information transmission efficiency and centrality of some brain regions continue to decline over time, perhaps related to their progressive cognitive impairment.

Graphical methods for understanding changes in states: Understanding medication use pathways

OBJECTIVES

As epidemiological studies become longer and larger, the field needs novel graphical methods to visualize complex longitudinal data. The aim of this study was to present the Slinkyplot, a longitudinal crosstabulation, to illustrate patterns of antidepressant use in a large prospective cohort of older adults with mild cognitive impairment.

METHODS

Data from the National Alzheimer's Coordinating Center are used to track switches between different states and types of antidepressant use. A Slinkyplot is populated with rows representing the state of medication use at each timepoint and columns representing the state at each subsequent visit.

RESULTS

The constructed Slinkyplots display the common practice of switching on and off different antidepressants over time, with citalopram, sertraline, and bupropion most commonly used followed by switching to another SSRI or SNRI as second-line treatment.

CONCLUSIONS

Slinkyplots are an innovative graphical means of visualizing complex patterns of transitions between different states over time for large longitudinal studies.

The complex relationship between depression and progression to incident cognitive impairment across race and ethnicity

INTRODUCTION

We examined baseline differences in depression and antidepressant use among cognitively normal older adults in five ethnoracial groups and assessed whether depression predicted a faster progression to incident cognitive impairment across groups.

METHODS

Data from the National Alzheimer's Coordinating Center (n = 8168) were used to examine differences between non-Hispanic Whites (nHW), African Americans (AA), Hispanics, Asians, and American Indian and Alaskan Natives in cross-sectional and longitudinal models.

RESULTS

AA had a lower risk of depression compared to nHW at baseline. No statistical interactions were noted between ethnoracial groups and depression. However, depression independently predicted a faster progression to incident cognitive impairment. Hispanics and Asian participants had a higher hazard for progression compared to nHW.

DISCUSSION

Previously established risk factors between depression and dementia were not found among AA and nHW participants. The relationship between depression and ethnoracial groups is complex and suggests differential effects on progression from cognitive normality to impairment.

Perspectives on the complex links between depression and dementia

This review highlights that depression is a growing health problem for the individual, and because of its high frequency in most societies, a growing burden on health care budgets. The focus of the review is the physiological links between depression and dementia, specifically Alzheimer’s disease. It suggests that depression is a significant risk factor for cognitive decline and explores the pathways that may lead depressed individuals to suffer this outcome. This review shows that depression and a number of its precursors activate pro-inflammatory mediators. These lead to cerebral small vessel disease with the consequent reduction in cerebral blood flow, which is known to precede cognitive decline. Thus, the impact of depression on the physiological events that lead to dementia is identical to the impact of other dementia risk factors recently reviewed. Depression is distinct, however, in being a relatively treatable condition, but the impact of treating depression on later cognitive decline is not always positive, leading to the hypothesis that only the antidepressants that attenuate inflammation alleviate subsequent cognitive decline.

The Role of Depressive Symptoms and Physical Activity Levels in Mediating the Association Between HIV Status and Neurocognitive Functions Among Individuals Aged at Least 50 Years in China: Cross-sectional Study

Background

Neurocognitive impairments are prevalent among older people in China. It is more problematic among older people living with HIV.

Objective

This study aims to compare neurocognitive performance between older people living with HIV and HIV-negative controls, and to explore whether the association between HIV status and neurocognitive performance was mediated by depressive symptoms and level of physical activity.

Methods

A cross-sectional study was conducted in Yongzhou, China. All people living with HIV aged ≥50 years listed in the registry were invited. Frequency matching was used to sample HIV-negative controls from the general population according to the distribution of age, sex, and years of formal education of older people living with HIV. A total of 315 older people living with HIV and 350 HIV-negative controls completed the face-to-face interview and comprehensive neuropsychological assessment of seven domains (learning, memory, working memory, verbal fluency, processing speed, executive function, and motor skills).

Results

As compared to HIV-negative controls, older people living with HIV performed worse in global score and all seven domains (P<.05). HIV infection was associated with higher depressive symptoms (P<.001) and lower level of physical activity (P<.001). Depressive symptoms and physical activity were negatively correlated (P<.001). Depressive symptoms and level of physical activity mediated the association between HIV status and global z-score and four domain z-scores of neurocognitive performance (learning, memory, verbal fluency, and processing speed).

Conclusions

Change in mental health and physical activity after HIV infection may partially explain why older people living with HIV are more susceptible to neurocognitive impairment. Promoting mental health and physical activity are potential entry points to slow down the progress of neurocognitive impairment among older people living with HIV.

Effect of Vortioxetine on Cognitive Impairment in Patients With Major Depressive Disorder: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Dementia and depression are increasingly common worldwide, and their effective control could ease the burden on economies, public health systems, and support networks. Vortioxetine is a new antidepressant with multipharmacologic actions that elevate the concentration of serotonin and modulate multiple neurotransmitter receptors in the brain. We conducted a meta-analysis to explore whether the cognitive function of patients with major depressive disorder (MDD) treated with vortioxetine would improve.

METHODS

We systematically reviewed randomized controlled trials (RCTs) in the PubMed, Embase, and Cochrane databases to assess the treatment effects of vortioxetine on the cognitive function of patients with MDD. The outcome measures included the Digit Symbol Substitution Test (DSST), Perceived Deficits Questionnaire (PDQ), and Montgomery-Åsberg Depression Rating Scale (MADRS) scores. Pooled results were calculated using a fixed-effects or random-effects model according to the heterogeneity of the included trials.

RESULTS

Six RCTs with a total of 1782 patients were included in the meta-analysis, which demonstrated that vortioxetine improved DSST, PDQ, and MADRS scores in patients with MDD. The results were consistent at the 10- and 20-mg doses. In the 20-mg group, the decrease in MADRS scores was more significant than that in the placebo group.

CONCLUSIONS

Both the 10- and 20-mg doses of vortioxetine can significantly increase DSST scores and decrease PDQ and MADRS scores in patients with MDD and cognitive dysfunction, but further studies with longer follow-up periods to assess mental function are required.

Comparison of moderate and vigorous walking exercise on reducing depression in middle-aged and older adults: A pilot randomized controlled trial

The optimal intensity of physical activity for alleviating depression in middle-aged and older adults remains unclear. The comparative effects of moderate and vigorous physical activity on reducing depression have not been directly examined. The World Health Organization (WHO) physical activity guidelines recommend adults and older adults to accumulate at least 150-300 minutes of moderate or 75-150 minutes of vigorous aerobic-type physical activity weekly or an equivalent combination of both for health benefits including reduced risk of depression. This parallel, assessor-blinded, pilot randomized controlled trial preliminarily compared the effectiveness of the minimal volume of aerobic-type physical activity at different intensities as recommended by WHO (150 minutes of moderate walking exercise and 75 minutes of vigorous walking exercise weekly) on alleviating depression in middle-aged and older adults. Middle-aged and older adults diagnosed with depression were randomized to the control group (CON), moderate walking exercise group (MOD), or vigorous walking exercise group (VIG). The exercise frequency of the moderate and vigorous walking exercise were three times a week and the intervention duration were 12 weeks. The primary outcome was the severity of depression assessed by Beck Depression Inventory. Secondary outcomes included severity of anxiety, sleep quality, quality of life, and cardiorespiratory fitness. Thirty participants completed the study (CON: n = 10, MOD: n = 10, VIG: n = 10). Participants in both MOD and VIG had significantly decreased depression severity after the intervention compared to CON (both p < 0.001). There was no significant difference between MOD and VIG (p = 0.92). Both MOD and VIG interventions also mitigated anxiety severity, improved quality of life and cardiorespiratory fitness. The minimum volume of walking exercise at either moderate or vigorous intensity was found to alleviate depression in middle-aged and older adults.Trial registration: ClinicalTrials.gov identifier: NCT04403373..

A Single-Case Design Investigation for Measuring the Efficacy of Gestalt Therapy to Treat Depression in Older Adults with Dementia in Italy and in Mexico: A Research Protocol

Psychotherapy is one of the evidence-based clinical interventions for the treatment of depression in older adults with dementia. Randomised controlled trials are often the first methodological choice to gain evidence, yet they are not applicable to a wide range of humanistic psychotherapies. Amongst all, the efficacy of the Gestalt therapy (GT) is under-investigated. The purpose of this paper is to present a research protocol, aiming to assess the effects of a GT-based intervention on people with dementia (PWD) and indirect influence on their family carers. The study implements the single-case experimental design with time series analysis that will be carried out in Italy and Mexico. Six people in each country, who received a diagnosis of dementia and present depressive symptoms, will be recruited. Eight or more GT sessions will be provided, whose fidelity will be assessed by the GT fidelity scale. Quantitative outcome measures are foreseen for monitoring participants' depression, anxiety, quality of life, loneliness, carers' burden, and the caregiving dyad mutuality at baseline and follow-up. The advantages and limitations of the research design are considered. If GT will effectively result in the treatment of depression in PWD, it could enrich the range of evidence-based interventions provided by healthcare services.

Mild Cognitive Impairment and modifiable risk factors among Lebanese older adults in primary care

OBJECTIVE

Mild Cognitive Impairment (MCI) is an intermediate state between normal cognition and dementia. Identification of MCI and associated risk factors is important for early intervention. This study investigated the prevalence of MCI among Lebanese older adults and associated risk factors in primary care.

METHODS

For this cross-sectional study, 337 adults aged 60 years and older met inclusion criteria and were recruited at a primary care clinic associated with a tertiary medical center in Beirut, Lebanon. The validated Arabic version of the Montreal Cognitive Assessment, the 5-item Geriatric Depression Scale, and the Lawton Instrumental Activities of Daily Living Scale were administered. Data about sociodemographic, behavioral, and clinical characteristics was obtained.

RESULTS

There was no difference in the mean age between those with normal cognition and those with MCI (mean age 70.38 ± 7.4 and 72.12 ± 7.6 years, respectively). The prevalence of MCI was 14.8% (50 out of 337), 42% were males and 58% were women. Participants having more than 12 years of education (OR = 0.297; CI = 0.112-0.788; P = 0.015) were less likely to have MCI. Participants with history of smoking (OR = 2.599; CI = 1.266-5.339; P = 0.012) or at risk of depression (OR = 2.847; CI = 1.392-5.819; P = 0.004) were more likely to have MCI.

CONCLUSION

Identification of patients with history of smoking and at risk of depression may serve as an opportunity to offer intensive counseling and targeted treatment to delay the onset or progression of MCI to Alzheimer's disease.

Depressive and Neurocognitive Disorders in the Context of the Inflammatory Background of COVID-19

The dysfunctional effects of the coronavirus disease 2019 (COVID-19) infection on the nervous system are established. The manifestation of neuropsychiatric symptoms during and after infection is influenced by the neuroinvasive and neurotrophic properties of SARS-CoV-2 as well as strong inflammation characterised by a specific "cytokine storm". Research suggests that a strong immune response to a SARS-CoV-2 infection and psychological stressors related to the pandemic may cause chronic inflammatory processes in the body with elevated levels of inflammatory markers contributing to the intensification of neurodegenerative processes. It is suggested that neuroinflammation and associated central nervous system changes may significantly contribute to the etiopathogenesis of depressive disorders. In addition, symptoms after a COVID-19 infection may persist for up to several weeks after an acute infection as a post-COVID-19 syndrome. Moreover, previous knowledge indicates that among SSRI (selective serotonin reuptake inhibitor) group antidepressants, fluoxetine is a promising drug against COVID-19. In conclusion, further research, observation and broadening of the knowledge of the pathomechanism of a SARS-CoV-2 infection and the impact on potential complications are necessary. It is essential to continue research in order to assess the long-term neuropsychiatric effects in COVID-19 patients and to find new therapeutic strategies.

Pilot testing of Dual-task Zumba Gold (DTZ) for community-dwelling people with mild cognitive impairment: A mixed-methods study

Dual-tasking (e.g., enrichment of physical activities with mental exercises) is an innovative strategy to enhance older adults' cognition. Meanwhile, Zumba is a popular dance program, but research is limited about its utility on older people or those with mild cognitive impairment (MCI). This study assessed the feasibility of a new intervention called dual-task Zumba Gold (DTZ) for people with MCI. A mixed-methods feasibility study involving ten people aged ≥55 years with MCI was conducted from December 2020 to March 2021. Nine participants completed the study (90%) with high intervention acceptability. Program adherence (90.3%) and implementation fidelity (92.2%) were high. Participants also expressed the program's benefits, challenges, and facilitators. Moreover, pilot test results suggested improvements in global cognition (Z=-2.680; p=0.007), quality of life (Z=-2.688; p=0.008), and mobility (Z=-2.333; p=0.020). Hence, DTZ is feasible and acceptable for people with MCI, offering potential multidomain effects. Future randomized controlled studies should confirm these outcomes.

Implementation of Pharmacist Reviews to Screen for Potentially Inappropriate Medications in Patients With Cognitive Impairment

Objective: To describe two pharmacist-led initiatives aimed to reduce potentially inappropriate medication (PIM) use in community-dwelling patients with dementia or cognitive impairment. Design: Retrospective, descriptive analysis of two clinical initiatives. Setting: Academic geriatric primary care clinics. Participants: Patients were included if they received a Memory Clinic pharmacist review May 1, 2017, to December 31, 2019, or a Living with Dementia (LWD) program pharmacist review November 15, 2018 to December 31, 2019 with provider follow-up within 6 months. Interventions: Both initiatives involved medication review by a clinical pharmacist to identify and make recommendations regarding medications that may contribute to cognitive impairment. The Memory Clinic served patients with concerns of cognitive impairment; whereas, the LWD program enrolled patients with an established diagnosis of dementia. Main Outcome Measure: Number of PIMs that could negatively impact cognition within each cohort. Additionally, 6-month implementation rates were analyzed for actionable pharmacist recommendations. RESULTS: Memory Clinic patients (n = 110) were taking an average of 2.4 PIMs; whereas, LWD patients (n = 40) were taking an average of 1.5 PIMs. Six-month implementation rates for all actionable pharmacist recommendations were 61.0% for the Memory Clinic and 42.4% for the LWD program. Specifically evaluating deprescribing recommendations, the 6-month PIM discontinuation rate was 63.6% for the Memory Clinic group and 60.0% for the LWD group. Conclusion: Pharmacists routinely identified PIMs during medication reviews, which led to successful recommendation implementation throughout multiple stages of cognitive decline. Both programs will continue to be adapted to ensure maximal impact.

The effect of systemic antidepressant treatments in early stage on neurocognitive function of euthymic bipolar patients initiated with a depressive onset: An observational, cross-sectional, single-blind study protocol

OBJECTIVES

Patients with bipolar disorder (BD) have a wide range of neurocognitive dysfunction even in euthymic state, leading to impaired psychosocial function and reduced quality of life. However, the understanding on risk factors related to neurocognitive impairment in such group of people is limited. In view of significantly delayed diagnosis of BD and common use of antidepressants prior to the BD diagnosis, the study aims to clarify whether systemic antidepressant use in early stage, defined as from the initial depressive episode to the diagnosis of BD, could impact neurocognitive function of euthymic bipolar patients.

METHODS

It is an observational, cross-sectional, single-blind trial, making a comparison in neurocognitive function between euthymic bipolar patients who had a depressive episode as initial onset and being with and without systemic antidepressant treatments in early stage (n = 62 and 62, respectively); secondary outcomes include the impact of systemic antidepressant use on global function, quality of life, sleep quality, positive and negative affect, and peripheral level of neuron-specific enolase.

DISCUSSION

The study will provide a comprehensive and in-depth understanding on the effect of systemic antidepressant treatments in early stage in such group of patients. It is expected to better guide the related prevention and treatment work of BD management.

TRIAL REGISTRATION

The study was registered on Clinicaltrials.gov with protocol ID (TJAH2020-18) and clinicaltrials.gov ID (NCT04564573).

Autophagy Induction and Accumulation of Phosphorylated Tau in the Hippocampus and Prefrontal Cortex of Adult C57BL/6 Mice Subjected to Adolescent Fluoxetine Treatment

BACKGROUND

Fluoxetine (FLX) represents the antidepressant of choice for the management of pediatric mood-related illnesses. Accumulating preclinical evidence suggests that ontogenic FLX exposure leads to deregulated affect-related phenotypes in adulthood. Mood-related symptomatology constitutes a risk-factor for various neurological disorders, including Alzheimer's disease (AD), making it possible for juvenile FLX history to exacerbate the development of neurodegenerative diseases.

OBJECTIVE

Because AD is characterized by the pathological accumulation of hyperphosphorylated tau, which can result from impaired function of protein degradation pathways, such as autophagy and the ubiquitin-proteasome system (UPS), we evaluated the long-term effects of adolescent FLX exposure on these pathways, using mice as a model system.

METHODS

We subjected C57BL/6 adolescent male mice to FLX (20 mg/kg/day) from postnatal day (PD) 35 to PD49. Twenty-one days after the last FLX injection (i.e., adulthood; PD70), mice were euthanized and, using immunoblotting analysis, we evaluated protein markers of autophagy (Beclin-1, LC3-II, p62) and the UPS (K48-pUb), as well as AD-associated forms of phosphorylated tau, within the hippocampus and prefrontal cortex.

RESULTS

Juvenile FLX pre-exposure mediated long-term changes in the expression of protein markers (increased LC3-II and decreased p62) that is consistent with autophagy activation, particularly in the prefrontal cortex. Furthermore, FLX history induced persistent accumulation of AD-associated variants of tau in both the hippocampus and prefrontal cortexConclusion: Adolescent FLX treatment may have enduring effects in the neuronal protein degradation machinery, which could adversely influence clearance of abnormal proteins, potentially predisposing individuals to developing AD in later life.

Depression, dementia and immune dysregulation

Major depression is a prevalent illness that increases the risk of several neurological conditions. These include stroke, cardiovascular disease, and dementia including Alzheimer's disease. In this review we ask whether certain types of depression and associated loneliness may be a harbinger of cognitive decline and possibly even dementia. We propose that chronic stress and inflammation combine to compromise vascular and brain function. The resulting increases in proinflammatory cytokines and microglial activation drive brain pathology leading to depression and mild cognitive impairment, which may progress to dementia. We present evidence that by treating the inflammatory changes, depression can be reversed in many cases. Importantly, there is evidence that anti-inflammatory and antidepressant treatments may reduce or prevent dementia in people with depression. Thus, we propose a model in which chronic stress and inflammation combine to increase brain permeability and cytokine production. This leads to microglial activation, white matter damage, neuronal and glial cell loss. This is first manifest as depression and mild cognitive impairment, but can eventually evolve into dementia. Further research may identify clinical subgroups with inflammatory depression at risk for dementia. It would then be possible to address in clinical trials whether effective treatment of the depression can delay the onset of dementia.

Geriatric Depression and Cognitive Impairment-An Update

BACKGROUND

Depression and cognitive impairment often coexist in older adults. The relation between depression and cognitive impairment is complex. The objective of this article is to review recent literature on cognitive impairment in older adults with depression and provide clinicians an update.

METHODS

We searched PubMed, Google Scholar, Science Direct, and Psych Info for the articles published in the English language related to late-life depression (LLD)/geriatric depression and cognitive impairment. We considered original research articles, relevant systematic reviews, chapters, and important conceptual articles published in the last 9 years (2011-2019). We selected relevant articles for this narrative review.

CONCLUSION

The concept pseudodementia, indicating depression with cognitive impairment mimicking dementia, is now seen only as a historical concept. The current literature strongly agrees with fact that cognitive deficits often exist in LLD. The cognitive deficits in depression were initially seen as trait marker; however, some recent studies suggest that cognitive deficits persist even in the remission phase. There is heterogeneity among the studies in terms of the nature of the cognitive deficits, but higher number of studies reported impairment in attention and executive function. LLD with cognitive deficits is at a higher risk of progression to dementia. In older adults, depression with cognitive impairments requires a comprehensive evaluation. Electroencephalography, event-related potentials, fluorodeoxyglucose-positron emission tomography, amyloid positron emission tomography, and CSF amyloid will supplement clinical evaluation in differentiating functional depressive disorder with cognitive impairment from depression with an underlying degenerative condition.

An update on antidepressant pharmacotherapy in late-life depression

Introduction: Clinically important depressive symptoms that occur in adults over age 60 are often termed late-life depression (LLD). LLD poses challenges for treating clinicians in both detection and treatment. Antidepressants are the most common first-line treatment approach. Older adults are at an increased risk of adverse effects because of polypharmacy.Areas covered: This article summarizes the challenges and approaches when using pharmacotherapy in LLD with a focus on newer data that have become available during the last five years. While no new antidepressants have become available during this period, a review of the literature summarizes advances in the knowledge of the adverse effects associated with various antidepressants and on the potential contribution of pharmacogenetic tools when prescribing antidepressants to older patients.Expert opinion: During the past 5 years, most of the literature relevant to the pharmacotherapy of MDD in older patients has focused on adverse effects. In particular, the effects of antidepressants on cognition and bone are emerging as important areas for clinical attention and further investigation. There is also an emerging literature on the potential role of pharmacogenetic testing in patients with MDD, though recommendations for use in older adults await larger studies that demonstrate its efficacy and cost-effectiveness.

Depression is Associated with Tau and Not Amyloid Positron Emission Tomography in Cognitively Normal Adults

BACKGROUND

Depression is also common with older age. Alzheimer's disease (AD) studies suggest that both cerebrospinal fluid and positron emission tomography (PET) amyloid biomarkers are associated with more depressive symptoms in cognitively normal older adults. The recent availability of tau radiotracers offers the ability to examine in vivo tauopathy. It is unclear if the tau biomarker is associated with depression diagnosis.

OBJECTIVE

We examined if tau and amyloid imaging were associated with a depression diagnosis among cognitively normal adults (Clinical Dementia Rating = 0) and whether antidepressants modified this relationship.

METHODS

Among 301 participants, logistic regression models evaluated whether in vivo PET tau was associated with depression, while another model tested the interaction between PET tau and antidepressant use. A second set of models substituted PET amyloid for PET tau. A diagnosis of depression (yes/no) was made during an annual clinical assessment by a clinician. Antidepressant use (yes/no) was determined by comparing medications the participants used to a list of 30 commonly used antidepressants. All models adjusted for age, sex, education, race, and apolipoprotein ɛ4. Similar models explored the association between the biomarkers and depressive symptoms.

RESULTS

Participants with elevated tau were twice as likely to be depressed. Antidepressant use modified this relationship where participants with elevated tau who were taking antidepressants had greater odds of being depressed. Relatedly, elevated amyloid was not associated with depression.

CONCLUSIONS

Our results demonstrate that tau, not amyloid, was associated with a depression diagnosis. Additionally, antidepressant use interacts with tau to increase the odds of depression among cognitively normal adults.

Deciphering the links between psychological stress, depression, and neurocognitive decline in patients with Down syndrome

The relationships between psychological stress and cognitive functions are still to be defined despite some recent progress. Clinically, we noticed that patients with Down syndrome (DS) may develop rapid neurocognitive decline and Alzheimer's disease (AD) earlier than expected, often shortly after a traumatic life event (bereavement over the leave of a primary caregiver, an assault, modification of lifestyle, or the loss of parents). Of course, individuals with DS are naturally prone to develop AD, given the triplication of chromosome 21. However, the relatively weak intensity of the stressful event and the rapid pace of cognitive decline after stress in these patients have to be noticed. It seems DS patients react to stress in a similar manner normal persons react to a very intense stress, and thereafter develop a state very much alike post-traumatic stress disorders. Unfortunately, only a few studies have studied stress-induced regression in patients with DS. Thus, we reviewed the biochemical events involved in psychological stress and found some possible links with cognitive impairment and AD. Interestingly, these links could probably be also applied to non-DS persons submitted to an intense stress. We believe these links should be further explored as a better understanding of the relationships between stress and cognition could help in many situations including individuals of the general population.

Depression in Alzheimer's Disease: A Delphi Consensus on Etiology, Risk Factors, and Clinical Management

Background: Alzheimer's disease (AD) and other forms of dementia are among the most common causes of disability in the elderly. Dementia is often accompanied by depression, but specific diagnostic criteria and treatment approaches are still lacking. This study aimed to gather expert opinions on dementia and depressed patient management to reduce heterogeneity in everyday practice. Methods: Prospective, multicenter, 2-round Modified Delphi survey with 53 questions regarding risk factors (11), signs and symptoms (7), diagnosis (8), and treatment (27) of depression in dementia, with a particular focus on AD. The questionnaire was completed by a panel of 37 expert physicians in neurodegenerative diseases (19 neurologists, 17 psychiatrists, and 1 geriatrician). Results: Consensus was achieved in 40 (75.5%) of the items: agreement in 33 (62.3%) and disagreement in 7 (13.2%) of them. Among the most relevant findings, depression in the elderly was considered an early sign (prodromal) and/or a dementia risk factor, so routine cognitive check-ups in depressed patients should be adopted, aided by clinical scales and information from relatives. Careful interpretation of neuropsychological assessment must be carried out in patients with depression as it can undermine cognitive outcomes. As agreed, depression in early AD is characterized by somatic symptoms and can be differentiated from apathy by the presence of sadness, depressive thoughts and early-morning awakening. In later-phases, symptoms of depression would include sleep-wake cycle reversal, aggressive behavior, and agitation. Regardless of the stage of dementia, depression would accelerate its course, whereas antidepressants would have the opposite effect. Those that improve cognitive function and/or have a dual or multimodal mode of action were preferred: Duloxetine, venlafaxine/desvenlafaxine, vortioxetine, tianeptine, and mirtazapine. Although antidepressants may be less effective than in cognitively healthy patients, neither dosage nor treatment duration should differ. Anti-dementia cholinesterase inhibitors may have a synergistic effect with antidepressants. Exercise and psychological interventions should not be applied alone before any pharmacological treatment, yet they do play a part in improving depressive symptoms in demented patients. Conclusions: This study sheds light on several unresolved clinical challenges regarding depression in dementia patients. Further studies and specific recommendations for this comorbid patient population are still needed.

Association of Midlife Depressive Symptoms with Regional Amyloid-β and Tau in the Framingham Heart Study

BACKGROUND

Depressive symptoms predict increased risk for dementia decades before the emergence of cognitive symptoms. Studies in older adults provide preliminary evidence for an association between depressive symptoms and amyloid-β (Aβ) and tau accumulation. It is unknown if similar alterations are observed in midlife when preventive strategies may be most effective.

OBJECTIVE

The study aim was to evaluate the association between depressive symptoms and cerebral Aβ and tau in a predominately middle-aged cohort with examination of the apolipoprotein (APOE) ɛ4 allele as a moderator.

METHODS

Participants included 201 adults (mean age 53±8 years) who underwent 11C-Pittsburgh Compound B amyloid and 18F-Flortaucipir tau positron emission tomography (PET) imaging. Depressive symptoms were evaluated with the Center for Epidemiological Studies Depression Scale (CES-D) at the time of PET imaging, as well as eight years prior. Associations between depressive symptoms at both timepoints, as well as depression (CES-D≥16), with regional Aβ and tau PET retention were evaluated with linear regression adjusting for age and sex. Interactions with the APOE ɛ4 allele were explored.

RESULTS

Depressive symptoms and depression were not associated with PET outcomes in the overall sample. However, among APOE ɛ4 allele carriers, there was a significant cross-sectional association between depressive symptoms and increased tau PET uptake in the entorhinal cortex (β= 0.446, SE = 0.155, p = 0.006) and amygdala (β= 0.350, SE = 0.133, p = 0.012).

CONCLUSION

Although longitudinal studies are necessary, the results suggest that APOE ɛ4 carriers with depressive symptoms may present with higher susceptibility to early tau accumulation in regions integral to affective regulation and memory consolidation.

Antiallergic drug desloratadine as a selective antagonist of 5HT2A receptor ameliorates pathology of Alzheimer's disease model mice by improving microglial dysfunction

Alzheimer's disease (AD) is a progressively neurodegenerative disease characterized by cognitive deficits and alteration of personality and behavior. As yet, there is no efficient treatment for AD. 5HT_2A receptor (5HT_2A R) is a subtype of 5HT₂ receptor belonging to the serotonin receptor family, and its antagonists have been clinically used as antipsychotics to relieve psychopathy. Here, we discovered that clinically first-line antiallergic drug desloratadine (DLT) functioned as a selective antagonist of 5HT_2A R and efficiently ameliorated pathology of APP/PS1 mice. The underlying mechanism has been intensively investigated by assay against APP/PS1 mice with selective 5HT_2A R knockdown in the brain treated by adeno-associated virus (AAV)-ePHP-si-5HT_2A R. DLT reduced amyloid plaque deposition by promoting microglial Aβ phagocytosis and degradation, and ameliorated innate immune response by polarizing microglia to an anti-inflammatory phenotype. It stimulated autophagy process and repressed neuroinflammation through 5HT_2A R/cAMP/PKA/CREB/Sirt1 pathway, and activated glucocorticoid receptor (GR) nuclear translocation to upregulate the transcriptions of phagocytic receptors TLR2 and TLR4 in response to microglial phagocytosis stimulation. Together, our work has highly supported that 5HT_2A R antagonism might be a promising therapeutic strategy for AD and highlighted the potential of DLT in the treatment of this disease.

Proton pump inhibitors and the risk of Alzheimer's disease and non-Alzheimer's dementias

Proton pump inhibitors (PPIs) are among the most prescribed medications. Previous epidemiological studies have presented contradictory results about PPIs and the risk of dementia. Our objective was to investigate the association between the use of PPIs and an increasing risk of incident AD or non-AD dementias. A community-based retrospective cohort study was conducted based on the data available from 1st January 2002 to 31st December 2015 in the Catalan health service (CatSalut) system. This cohort included all PPI users (N = 36,360) and non-users (N = 99,362). A lag window of 5 years was considered between the beginning of the PPI treatment and the diagnosis of dementia. PPI use was not associated with the risk of AD (adjusted odds ratio (OR) 1.06) (95% CI 0.93–1.21; p = 0.408). A weakly but significantly increased risk of non-AD dementias was observed among PPI users (adjusted OR 1.20, 95% CI 1.05–1.37; p = 0.007). A higher dose of PPIs was not associated with an increased risk of either AD or non-AD dementias (OR 1.20; 95% CI 0.91–1.61 and OR 0.95; 95% CI 0.74–1.22, respectively). Regarding the number of PPIs used, we observed an increased risk of AD (OR 1.47; 95% CI 1.18–1.83) and non-AD dementias (OR 1.38; 95% CI 1.12–1.70) in users of two types of PPIs compared with those who used only one type. We did not find a higher incidence of AD among PPI users, but a weak increase in the risk of non-AD dementias among PPI users was observed.

Cognition in offspring of parents with psychotic and non-psychotic severe mental illness

BACKGROUND

Cognitive impairment is a feature of severe mental illness (SMI; schizophrenia, bipolar disorder, major depressive disorder). Psychotic forms of SMI may be associated with greater cognitive impairment, but it is unclear if this differential impairment pre-dates illness onset or whether it reflects a consequence of the disorder. To establish if there is a developmental impairment related to familial risk of psychotic SMI, we investigated cognition in offspring of parents with psychotic and non-psychotic SMI.

METHOD

Participants included 360 children and youth (mean age 11.10, SD 4.03, range 6-24), including 68 offspring of parents with psychotic SMI, 193 offspring of parents with non-psychotic SMI, and 99 offspring of control parents. The cognitive battery assessed a range of functions using standardized tests and executive function tasks from the Cambridge Automated Neuropsychological Test Battery.

RESULTS

Compared to controls, offspring of parents with psychotic SMI performed worse on overall cognition (β = -0.32; p < 0.001) and 6 of 15 cognitive domains, including verbal intelligence, verbal working memory, processing speed, verbal learning and memory, verbal fluency, and sustained attention. Offspring of parents with non-psychotic SMI performed worse than controls on 3 of the 15 domain specific cognitive tests, including verbal intelligence, visual memory and decision-making.

CONCLUSIONS

Widespread mild-to-moderate cognitive impairments are present in young offspring at familial risk for transdiagnostic psychotic SMI. Offspring at familial risk for non-psychotic SMI showed fewer and more specific impairments in the domains of verbal intelligence, visual memory and decision-making.

Understanding the Association Between Antidepressants and the Risk of Being Diagnosed with Dementia in Older People: A Self-Controlled Case Series Study

BACKGROUND

Given concerns about adverse outcomes for older people taking antidepressants in the literature, we investigated whether taking antidepressants elevates the risk of dementia.

OBJECTIVE

This study aims to investigate the putative association of antidepressants with the risk of dementia.

METHODS

We conducted a population-based self-controlled case series analysis of older people with dementia and taking antidepressants, using territory-wide medical records of 194,507 older patients collected by the Hospital Authority of Hong Kong, to investigate the association between antidepressant treatment and the risk of developing dementia in older people.

RESULTS

There was a significantly higher risk of being diagnosed with dementia during the pre-drug-exposed period (incidence rate ratio (IRR) 20.42 (95% CI: 18.66-22.34)) compared to the non-drug-exposed baseline period. The IRR remained high during the drug-exposed period (IRR 8.86 (7.80-10.06)) before returning to a baseline level after washout (IRR 1.12 (0.77-1.36)).

CONCLUSION

The higher risk of dementia before antidepressant treatment may be related to emerging psychiatric symptoms co-occurring with dementia, which trigger medical consultations that result in a decision to begin antidepressants. Our findings do not support a causal relationship between antidepressant treatment and the risk of dementia.

Pharmacotherapy of Behavioral and Psychological Symptoms of Dementia: State of the Art and Future Progress

The core symptoms of different dementia subtypes are the behavioral and psychological symptoms of dementia (BPSD) and its neuropsychiatric symptoms (NPS). BPSD symptoms may occur at any stage in the case of dementia due to Alzheimer's disease (AD), whereas they tend to occur early on in the case of its behavioral variant frontotemporal dementia or dementia with Lewy bodies and are essential for diagnosis. BPSD treatment consists of non-pharmacological as well as pharmacological interventions, with non-pharmacological interactions being suggested as first-line treatment. Agitation, psychotic features, apathy, depression, and anxiety may not respond to acetylcholinesterase inhibitors or memantine in AD cases; therefore, antipsychotics, antidepressants, sedative drugs or anxiolytics, and antiepileptic drugs are typically prescribed. However, such management of BPSD can be complicated by hypersensitivity to antipsychotic drugs, as observed in DLB, and a lack of effective pro-cognitive treatment in the case of frontotemporal dementia. The present paper reviews current knowledge of the management of BPSD and its limitations and discusses on-going clinical trials and future therapeutic options.

Non-Cancer Chronic Pain Conditions and Risk for Incident Alzheimer's Disease and Related Dementias in Community-Dwelling Older Adults: A Population-Based Retrospective Cohort Study of United States Medicare Beneficiaries, 2001-2013

Accumulating evidence suggests that certain chronic pain conditions may increase risk for incident Alzheimer's disease and related dementias (ADRD). Rigorous longitudinal research remains relatively sparse, and the relation of overall chronic pain condition burden to ADRD risk remains little studied, as has the potential mediating role of sleep and mood disorders. In this retrospective cohort study, we investigated the association of common non-cancer chronic pain conditions (NCPC) at baseline to subsequent risk for incident ADRD, and assessed the potential mediating effects of mood and sleep disorders, using baseline and 2-year follow-up data using 11 pooled cohorts (2001-2013) drawn from the U.S. Medicare Current Beneficiaries Survey (MCBS). The study sample comprised 16,934 community-dwelling adults aged ≥65 and ADRD-free at baseline. NCPC included: headache, osteoarthritis, joint pain, back or neck pain, and neuropathic pain, ascertained using claims data; incident ADRD (N = 1149) was identified using claims and survey data. NCPC at baseline remained associated with incident ADRD after adjustment for sociodemographics, lifestyle characteristics, medical history, medications, and other factors (adjusted odds ratio (AOR) for any vs. no NCPC = 1.21, 95% confidence interval (CI) = 1.04-1.40; p = 0.003); the strength and magnitude of this association rose significantly with increasing number of diagnosed NCPCs (AOR for 4+ vs. 0 conditions = 1.91, CI = 1.31-2.80, p-trend < 0.00001). Inclusion of sleep disorders and/or depression/anxiety modestly reduced these risk estimates. Sensitivity analyses yielded similar findings. NCPC was significantly and positively associated with incident ADRD; this association may be partially mediated by mood and sleep disorders. Additional prospective studies with longer-term follow-up are warranted to confirm and extend our findings.

Comparison of Donepezil, Memantine, Melatonin, and Liuwei Dihuang Decoction on Behavioral and Immune Endocrine Responses of Aged Senescence-Accelerated Mouse Resistant 1 Mice

Aging is a natural biological process associated with cognitive decline and neuroendocrine–immune system changes; the neuroendocrine–immune system plays crucial role in brain aging and neurodegeneration, and it is essential to discern beneficial attempts to delay the aging progress based on immunological aging. In this study, we have investigated the effects of Traditional Chinese Medicine (TCM)—Liuwei Dihuang decoction (LW)—and donepezil, memantine, and melatonin on cognitive decline in aging mice. The aged SAMR1 mice received oral administration of donepezil (1mg/kg), memantine (10 mg/kg), melatonin (10 mg/kg), and LW (10 g/kg) for 3 months. A shuttle box, Morris water maze, and elevated-zero maze were performed to assess cognitive function, and flowcytometry, Luminex, and radioimmunoassay were performed to measure the lymphocyte subsets, inflammatory factors, and hormones. We observed that survival days of mice was increased with melatonin and LW, the anxiety behavior was significantly improved by memantine, melatonin, and LW treatment, active avoidance responses significantly improved by LW, donepezil, and memantine, the spatial learning ability was significantly improved by donepezil, and LW and melatonin were beneficial to the spatial memory of old mice. For immune function, LW increased CD4⁺ and CD4⁺CD28⁺ cells and reduced TNF-α, IL-1β, and G-CSF in plasma, and it also promoted the secretion of anti-inflammatory factors IL-4, IL-5, and IL-10 by regulating the active of Th2 cells in spleen. Donepezil and memantine exerted protective effects against CD4⁺CD28⁺ cell decrease caused by aging and reduced the pro-inflammatory factors TNF-α, IL-1β, and G-CSF in plasma. Melatonin could reverse CD8⁺CD28⁺ cell imbalances and increased B cells. For endocrine factors, LW increased TSH levels in the pituitary, and melatonin increased the GH level in blood. Our findings indicated that LW improved the cognitive decline in aging mice, and this might be associated with modulation of the active T cells and HPG axis hormones as well as increasing anti-inflammatory factors. Meanwhile, donepezil and memantine have advantages in regulating adaptive immunity, melatonin has advantages in the regulation of B cells and pituitary hormones, and LW exhibits a better effect on neuroendocrine immune function compared with the others from a holistic point of view. LW might be a potential therapeutic strategy for anti-aging-related syndromes, and it can also provide a value on medication guidance about drug combinations or treatment in clinic.

Efficacy and tolerability of paroxetine in adults with social anxiety disorder: A meta-analysis of randomized controlled trials

OBJECTIVE

The present study aimed to estimate the comprehensive efficacy and tolerability of paroxetine in adult patients with social anxiety disorder (SAD).

METHODS

We conducted a comprehensive literature review of the PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and ClinicalTrials databases for eligible randomized controlled trials (RCTs). The efficacy outcome was the mean change of different kinds of scale scores as well as response and remission rates. The secondary outcome was tolerability, defined as the discontinuation rate and the incidence of adverse events (AEs).

RESULTS

Our meta-analysis included 13 RCTs. Mean changes in the Liebowitz Social Anxiety Scale (LSAS) total score, fear and avoidance subscale of LSAS scores were all significantly greater in patients with SAD that received paroxetine compared to those received placebo (total: MD = 13.46, 95%CI 10.59-16.32, P < .00001; fear: MD = 6.76, 95%CI 4.89-8.62, P < .00001; avoidance: MD = 6.54, 95%CI 4.63-8.45, P < .00001). Response and remission rates were both significantly greater in patients with SAD that received paroxetine compared to those received placebo (response: OR = 3.02, 95%CI 2.30-3.97, P < .00001; remission: OR = 3.14, 95%CI 2.25-4.39, P < .00001). There was no significant difference in discontinuation rate due to any reason between two groups (OR = 1.06, 95%CI 0.81-1.39, P = .65). Discontinuation rate due to AEs was higher in paroxetine than placebo group (OR = 3.41, 95%CI 2.45-4.72, P < .00001) whereas the rate due to lack of efficacy was higher in placebo as compared with paroxetine group (OR = 0.14, 95%CI 0.09-0.22, P < .00001). The incidence of any AE was significantly increased in patients that received paroxetine (OR = 1.83, 95%CI 1.43-2.35, P < .00001).

CONCLUSION

Paroxetine was an effective and well-tolerated treatment option for adult patients with SAD.

Structure-activity relationships of sulfonamides derived from carvacrol and their potential for the treatment of Alzheimer's disease

Five synthetic sulfonamides derived from carvacrol, a natural product and a small molecule with druglike properties, were evaluated with respect to their effects on the cognitive deficits of animals with streptozotocin (STZ)-induced Alzheimer's disease (AD). Memory, ambulation, anxiety and oxidative stress were evaluated. In vitro assays were performed to assess the inhibition of acetylcholinesterase (AChE), and the data were combined with molecular docking for the establishment of structure-activity relationships. The memories of animals treated with the compounds derived from morpholine (1), hydrazine (3) and 2-phenol (5) were improved. Compound 3 was the most promising, yielding excellent results in the inhibitory avoidance test. Moreover, the compounds did not exhibit any deleterious effects on the animals' ambulation in the open field test. Molecular docking confirmed the results obtained in the AChE inhibition assay. In short, compounds 1, 3 and 5 can reduce STZ-induced deficits and show potential for the treatment of Alzheimer's. In addition, these agents produce significant anxiolytic and antioxidant effects.

Estimating associations between antidepressant use and incident mild cognitive impairment in older adults with depression

INTRODUCTION

Previous studies have provided equivocal evidence of antidepressant use on subsequent cognitive impairment; this could be due to inconsistent modeling approaches. Our goals are methodological and clinical. We evaluate the impact of statistical modeling approaches on the associations between antidepressant use and risk of Mild Cognitive Impairment (MCI) in older adults with depression.

METHODS

716 participants were enrolled. Our primary analysis employed a time-dependent Cox proportional hazards model. We also implemented two fixed-covariate proportional hazards models-one based on having ever used antidepressants during follow-up, and the other restricted to baseline use only.

RESULTS

Treating antidepressant use as a time-varying covariate, we found no significant association with incident MCI (HR = 0.92, 95% CI: 0.70, 1.20). In contrast, when antidepressant use was treated as a fixed covariate, we observed a significant association between having ever used antidepressants and lower risk of MCI (HR = 0.40, 95% CI: 0.28, 0.56). However, in the baseline-use only model, the association was non-significant (HR = 0.84, 95% CI: 0.60, 1.17).

DISCUSSION

Our results were dependent upon statistical models and suggest that antidepressant use should be modeled as a time-varying covariate. Using a robust time-dependent analysis, antidepressant use was not significantly associated with incident MCI among cognitively normal persons with depression.

Depression and Alzheimer's Disease Biomarkers Predict Driving Decline

BACKGROUND

Symptomatic Alzheimer's disease (AD) and depression independently increase crash risk. Additionally, depression is both a risk factor for and a consequence of AD.

OBJECTIVE

To examine whether a depression diagnosis, antidepressant use, and preclinical AD are associated with driving decline among cognitively normal older adults.

METHODS

Cognitively normal participants, age ≥65, were enrolled. Cox proportional hazards models evaluated whether a depression diagnosis, depressive symptoms (Geriatric Depression Scale), antidepressant use, cerebrospinal fluid (amyloid-β42 [Aβ42], tau, phosphorylated tau181 [ptau181]), and amyloid imaging biomarkers (Pittsburgh Compound B and Florbetapir) were associated with time to receiving a rating of marginal/fail on a road test. Age was adjusted for in all models.

RESULTS

Data were available from 131 participants with age ranging from 65.4 to 88.2 years and mean follow up of 2.4 years (SD = 1.0). A depression diagnosis was associated with a faster time to receiving a marginal/fail rating on a road test and antidepressant use (p = 0.024, HR = 2.62). Depression diagnosis and CSF and amyloid PET imaging biomarkers were associated with driving performance on the road test (p≤0.05, HR = 2.51-3.15). In the CSF ptau181 model, depression diagnosis (p = 0.031, HR = 2.51) and antidepressant use (p = 0.037, HR = 2.50) were statistically significant predictors. There were no interaction effects between depression diagnosis, antidepressant use, and biomarker groups. Depressive symptomology was not a statistically significant predictor of driving performance.

CONCLUSIONS

While, as previously shown, preclinical AD alone predicts a faster time to receiving a marginal/fail rating, these results suggest that also having a diagnosis of depression accelerates the onset of driving problems in cognitively normal older adults.

Antidepressant Use and Cognitive Outcomes in Very Old Women

Background

Antidepressant use is very common in the elderly, but the effects of antidepressants on cognition in the elderly are controversial with some studies suggesting harm and others protection. We aimed to investigate the association between different antidepressant use and change in cognition and risk of mild cognitive impairment (MCI) or dementia in very old women.

Methods

We examined 1,234 community-dwelling women (mean age 83.2 years) from the Study of Osteoporotic Fractures. Baseline antidepressant use was reported and verified by medication containers, and medications were coded with computerized dictionary. Cognitive status (normal, MCI, or dementia) was adjudicated by an expert clinical panel 5 years later. Change in a short-form Mini-Mental State Examination and Trails B were evaluated over 5 years.

Results

Eleven per cent of the women were taking antidepressants. Users of selective serotonin reuptake inhibitors (SSRIs) had the greatest cognitive decline over 5 years, after adjustment for demographics, medical comorbidities, benzodiazepine use, and baseline cognition. Multivariable logistic regression shows that the users of SSRIs were more than twice (OR = 2.69, 95% CI = 1.64-4.41) and trazodone users more than three times (3.48, 1.12-10.81) as likely to develop MCI or dementia compared with the nonusers. Further adjustment for baseline cognition or depressive symptoms did not appreciably alter the results, and the association remained after excluding women with high depressive symptoms. The use of tricyclic antidepressants or other antidepressants was not significantly associated with cognitive outcomes.

Conclusions

The use of antidepressants, especially SSRIs and trazodone, was associated with an increased risk of cognitive impairment 5 years later among the oldest old women.

γ-[Glu]n-Trp ameliorates anxiety/depression-like behaviors and its anti-inflammatory effect in an animal model of anxiety/depression

This study compared the abilities of γ-[Glu]n-Trp (EW) and whey protein hydrolysate (WPH) with a high ratio of Trp : 5 large neutral amino acids (5LNAAs) to reverse chronic restraint stress-corticosterone injection induced anxiety/depression-like behaviors in C57BL/6 male mice. EW was synthesized using l-glutaminase from Bacillus amyloliquefaciens. Acid protease, trypsin, pancreatin or flavorzyme was used to produce WPHs. The WPH with the highest Trp/5LNAAs ratio (17.38%; by trypsin) was selected for animal trials. EW (dose 2.0, 5.0 or 10.0 mg kg^-1 d^-1) and WPH (dose 0.5, 1.0 or 2.0 mg g^-1 d^-1) reversed behavioral dysfunctions, suppressed serum inflammatory cytokines (TNF-α, IL-6, IL-1β and IFN-γ), and reduced the activity of indoleamine 2,3-dioxygenase (key rate-limiting enzyme of the kynurenine pathway) while increasing the activity of tryptophan hydroxylase (key rate-limiting enzyme of the serotonin pathway) in the hypothalamus, hippocampus and prefrontal cortex, with EW acting more effectively. EW could also increase body weight gain and might act more effectively via the kynurenine pathway. These findings are of significance to promote the future practical application of kokumi γ-[Glu]n-Trp peptides.

Herbal medicine for post-stroke anxiety: A systematic review and meta-analysis of randomized controlled trials

The study was conducted to investigate the efficacy and safety of herbal medicine (HM) for post-stroke anxiety (PSA). Through comprehensive searches, twenty randomized controlled trials were included. Meta-analysis showed that compared to the HM group, the conventional pharmacotherapy group showed significantly lower Hamilton anxiety rating scale (HAMA) score after 1 week of treatment, but not after 2, 4, and 6 weeks of treatment, and higher HAMA score after 8 weeks and 3 months of treatment. Meanwhile, compared to the conventional pharmacotherapy alone group, the HM plus conventional pharmacotherapy group showed significantly better results in HAMA score after 2, 4, 6, and 8 weeks of treatment. HM group was associated with lower incidence of adverse events. Current evidence suggests that HM or HM plus conventional pharmacotherapy may be safe and effective in PSA patients within a certain time period. However, due to limited strength of evidence, definite conclusions are not possible.

Neuroinflammation and amyloid-beta 40 are associated with reduced serotonin transporter (SERT) activity in a transgenic model of familial Alzheimer's disease

Background

Discrepant and often contradictory results have accumulated regarding the antidepressant and pro-cognitive effects of serotonin transporter (SERT) antagonists in Alzheimer’s disease.

Methods

To address the discrepancy, we measured the activity and density of SERT in the neocortex of 3–24-month-old APP_swe/PS1_dE9 and wild-type littermate mice, by using [³H]DASB autoradiography and the [³H]5-HT uptake assay. Levels of soluble amyloid-β (Aβ), and pro-inflammatory cytokines that can regulate SERT function, such as interleukin-1β (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor (TNF), were measured in parallel. Neuroinflammation in aging APP_swe/PS1_dE9 mice was further evaluated by [³H]PK11195 autoradiography.

Results

Decreased SERT density was observed in the parietal and frontal cortex of 18–24-month-old APP_swe/PS1_dE9 mice, compared to age-matched, wild-type animals. The maximal velocity uptake rate (V_max) of [³H]5-HT was reduced in neocortical preparations from 20-month-old transgenic vs. wild-type mice. The reduction was observed when the proportion of soluble Aβ₄₀ in the Aβ_40/42 ratio increased in the aged transgenic brain. At concentrations compatible with those measured in 20-month-old APP_swe/PS1_dE9 mice, synthetic human Aβ₄₀, but not Aβ₄₂, reduced the baseline V_max of [³H]5-HT by ~ 20%. Neuroinflammation in APP_swe/PS1_dE9 vs. wild-type mice was evidenced by elevated [³H]PK11195 binding levels and increased concentration of IL-1β protein, which preceded the reductions in neocortical SERT density and activity. Age-induced increases in the levels of IL-1β, IL-6, and TNF were observed in both transgenic and wild-type animals.

Conclusions

The progression of cerebral amyloidosis is associated with neuroinflammation and decreased presynaptic markers of serotonergic integrity and activity. The Aβ₄₀-induced reduction in the uptake kinetics of [³H]5-HT suggests that the activity of SERT, and potentially the effects of SERT antagonism, depend on the levels of interstitial Aβ₄₀.

Health-Promoting Strategies for the Aging Brain

As the world's population ages and people live longer, the changes in the aging brain present substantial challenges to our health and society. With greater longevity come age-related diseases, many of which have direct and indirect influences on the health of the brain. Although there is some degree of predictable decline in brain functioning with aging, meaningful cognitive decline is not inevitable and is perhaps preventable. In this review, we present the case that the course of aging-related brain disease and dysfunction can be modified. We present the evidence for conditions and risk factors that may contribute to cognitive decline and dementia and for interventions that may mitigate their impact on cognitive functioning later in life, or even prevent them and their cognitive sequelae from developing. Although much work remains to be done to meet the challenges of the aging brain, strategies to promote its health have been demonstrated and offer much promise, which can only be realized if we mount a vigorous public health effort to implement these strategies.

Relevant factors of depression in dementia modifiable by non-pharmacotherapy: a systematic review

Depression in dementia patients is associated with complications such as decreased activities of daily living and decreased quality of life. Because pharmacotherapeutic treatments for depression in dementia patients may have a poor risk-benefit ratio, effective non-pharmacotherapeutic interventions are favourable. However, the development of effective treatments requires the identification of depression-associated factors that can be modified by non-pharmacotherapeutic means in dementia patients. This systematic literature review aimed to identify modifiable factors related to depression and confirm that these factors can be improved by non-pharmacotherapeutic interventions. We searched PubMed, SpringerLink, the Web of Science, and the Cochrane Library for articles published between June 2007 and June 2017. We included studies that investigated causes of depression in dementia patients and excluded studies with unclear dementia diagnostic criteria or operational definitions. Of 9004 records screened, 6 studies were included. The participants included community-dwelling individuals and long-term care facility residents. The severity of dementia varied from mild to severe. After reviewing the studies, we identified five modifiable relevant factors in community-dwelling individuals: (i) pain; (ii) neuropsychiatric symptoms; (iii) cognitive decline; (iv) social isolation; and (v) quality of life. In long-term care facility residents, we identified neuropsychiatric symptoms and quality of life as relevant factors. Our results indicated that non-pharmacological interventions that improve these factors may improve symptoms of depression. A longitudinal study is recommended to clarify the mechanisms underlying depression symptoms and treatment in dementia patients. In addition, further investigation is needed to elucidate the ways in which differing dementia types and severity affect symptoms of depression.