Does depression in old age increase only cardiovascular mortality? The Leiden 85-plus Study

Association of Depression and Cardiovascular Disease

BACKGROUND

Cardiovascular disease remains the leading worldwide cause of mortality. There has been increased awareness of the impact of psychological health on cardiovascular disease. In particular, major depression has been linked to increased all-cause mortality, development of cardiovascular disease, and worse outcomes in those with existing cardiovascular disease.

METHODS

We conducted a meta-analysis assessing the incidence of cardiovascular disease and cardiovascular disease outcomes among those with major depressive disorder.

RESULTS

Among 26 studies of 1,957,621 individuals, depression was associated with increased risk of incident stroke (hazard ratio [HR] 1.13; 95% confidence interval [CI], 1.00-1.28), myocardial infarction (HR 1.28; 95% CI, 1.14-1.45), congestive heart failure (HR 1.04; 95% CI, 1.00-1.09), or any cardiovascular disease (HR 1.16; 95% CI, 1.04-1.30). Depression was associated with increased risk of all-cause mortality (HR 1.43; 95% CI, 1.27-1.60), cardiovascular disease mortality (HR 1.44; 95% CI, 1.27-1.63), and congestive heart failure mortality (HR 3.20; 95% CI, 1.29-7.94).

CONCLUSION

Depression has a significant negative impact on development of cardiovascular disease and on cardiovascular disease outcomes. Further efforts to understand and mitigate these impacts are prudent.

No effect of thyroid hormones on 5-year mortality in patients with subjective cognitive decline, mild cognitive disorder, and Alzheimer's disease

The present study aimed to investigate differences in circulating thyroid hormone levels, gender, education, depressive symptoms, and cognitive performance among patients with cognitive impairment, and also to examine their associations, as well as that of cognitive decline, with 5-year mortality. Between 1998 and 2017, a hospital-based, single-centre (Neurology Department of the General Hospital in Vienna, Austria), retrospective follow-up study enrolled 2102 patients with mild to severe cognitive impairment (grouped into subjective cognitive decline, mild cognitive impairment, and Alzheimer's disease). Cox proportional hazards models were used to calculate hazard ratios (HRs), with 95% confidence intervals (CIs), as well as to calculate stepwise adjustments for demographic variables (age, gender, and education), depressive symptoms (Geriatric Depression Scale, GDS-15), and neuropsychological abilities (four domains of a neuropsychological test battery of Vienna, NTVB). In univariate analyses, total triiodothyronine (TT3) levels differed significantly between Alzheimer's disease and mild cognitive impairment patients (p_diff  = .001). No other differences in cognitive impairment subgroups with any of the measured thyroid hormones were observed. Furthermore, in multivariate models, circulating TT3 was not associated with mortality (multivariable-adjusted HR per unit increase in TT3 = 0.56; 95% CI = 0.29-1.07). In multivariate models, we observed significantly lower 5-year mortality among women (HR = 0.56; 95% CI = 0.43-0.73) and those who scored higher on any of the four domains of the NBTV (e.g., attention and perceptual speed, HR = 0.63; 95% CI = 0.54-0.72); we also observed significantly higher 5-year mortality among patients with depressive symptoms (HR per one point score increase in GDS-15 = 1.06; 95% CI = 1.02-1.10), regardless of cognitive impairment subgroup. Among patients with various degrees of cognitive impairment, we found no associations of thyroid hormone levels with 5-year mortality. Gender, neuropsychological abilities, and depressive symptoms were each significant predictors of 5-year mortality. These results suggest that a neurocognitive test performance could serve as an important predictor of 5-year mortality among patients with cognitive impairment, although further studies with a more complete adjustment for comorbidities are needed to confirm these findings.

Combined influence of depressive symptoms and systemic inflammation on all-cause and cardiovascular mortality: evidence for differential effects by gender in the English Longitudinal Study of Ageing

BACKGROUND

Depressive symptoms and inflammation are risk factors for cardiovascular disease (CVD) and mortality. We investigated the combined association of these factors with the prediction of CVD and all-cause mortality in a representative cohort of older men and women.

METHODS

We measured C-reactive protein (CRP) and depressive symptoms in 5328 men and women aged 52-89 years in the English Longitudinal Study of Ageing. Depressive symptoms were measured using the eight-item Centre for Epidemiological Studies Depression Scale. CRP was analysed from peripheral blood. Mortality was ascertained from national registers and associations with depressive symptoms and inflammation were estimated using Cox proportional hazard models.

RESULTS

We identified 112 CVD related deaths out of 420 all-cause deaths in men and 109 CVD related deaths out of 334 all-cause deaths in women over a mean follow-up of 7.7 years. Men with both depressive symptoms and high CRP (3-20 mg/L) had an increased risk of CVD mortality (hazard ratio; 95% confidence interval: 3.89; 2.04-7.44) and all-cause mortality (2.40; 1.65-3.48) after adjusting for age, socioeconomic variables and health behaviours. This considerably exceeds the risks associated with high CRP alone (CVD 2.43; 1.59-3.71, all-cause 1.49; 1.20-1.84). There was no significant increase in mortality risk associated with depressive symptoms alone in men. In women, neither depressive symptoms or inflammation alone or the combination of both significantly predicted CVD or all-cause mortality.

CONCLUSIONS

The combination of depressive symptoms and increased inflammation confers a considerable increase in CVD mortality risk for men. These effects appear to be independent, suggesting an additive role.

Depression, cardiac mortality and all-cause mortality

Depression is an illness that kills. The links between depression and medical illness are well established and bi-directional, but evidence is mounting that depression increases mortality as well as morbidity in adults, particularly older adults. We examine the evidence that the increase in mortality in depression applies to all-cause mortality as well as cardiac mortality, and describe plausible physiological theories for the association. We conclude that excess mortality arising from depression is a major public health problem that is largely unrecognised and needs to be addressed by a range of clinicians.

Apathy in early and late-life depression

BACKGROUND

Late-life depression is thought to differ in clinical presentation from early-life depression. Particularly, late-life depression is considered to be more characterized by apathy than is early-life depression. Lacking convincing evidence, this study examines the presence and associated socio-demographic/clinical characteristics of apathy in older compared to younger depressed persons.

METHODS

This cross-sectional study used data from two naturalistic cohort studies, i.e. the Netherlands Study of Depression in Older Persons (NESDO) and the Netherlands Study of Depression and Anxiety (NESDA). These studies included 605 persons (aged 18-93 years) with a major depressive disorder, divided into 217 early-life (< 60 years) and 388 late-life (≥ 60 years) depressed persons. Apathy was considered present if a score of ≥14 on the Apathy Scale.

RESULTS

Apathy was strongly associated with age: it was more frequently present in persons with late-life depression (74.5%) than in those with early-life depression (53.5%). Independent of age, the following characteristics were associated with the presence of apathy: male gender, low education, use of benzodiazepines, chronic diseases, and more severe depression. Of all potential risk factors, only former and current smoking was associated with the presence of apathy in older depressed persons but not in younger depressed persons (p-value for age interaction = 0.01).

LIMITATIONS

No causal relationships can be drawn due to the cross-sectional design of the study.

CONCLUSIONS

In depressed individuals, clinically relevant apathy was more frequently present in older compared to younger persons. Both age groups showed largely the same associated risk factors. Apathy was independently associated with older age, male gender and more severe depression.

Exploring the excess mortality due to depressive symptoms in a community-based sample: The role of Alzheimer's Disease

BACKGROUND

Depression has been associated with increased risk of death. However, there is lack of studies exploring such relationship in the context of dementia. Given the high prevalence of both depression and Alzheimer's Disease (AD), investigating their temporal association with mortality is of public health relevance.

METHODS

Longitudinal data from the WHICAP study were analyzed (1958 individuals aged ≥65 years). Depressive symptoms were assessed with the 10-item Center for Epidemiologic Studies Depression Scale (CES-D). Respondents were identified as having AD if they satisfied the criteria of the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease. Cox regressions analyses were performed to determine the association between depressive symptoms and risk of all-cause mortality using the overall sample, and by AD status.

RESULTS

Depressive symptoms were significantly associated with higher mortality risk after adjusting for all potential covariates in the overall sample (HR=1.22; 95% CI=1.02, 1.46) and in individuals with incident AD (HR=1.88; 95% CI=1.12, 3.18).

LIMITATIONS

The CES-D does not measure clinical depression but depressive symptomatology. Since those who were exposed to known risk factors for mortality are likely to die prematurely, our results may have been skewed to the individuals with longer survival.

CONCLUSIONS

Strategies focusing on prevention and early treatment of depression in the elderly may have a beneficial effect not only on patient quality of life and disability, but may also increase survival in the context of AD.

Duration of depressive symptoms and mortality risk: the English Longitudinal Study of Ageing (ELSA)

BACKGROUND

The relationship between the duration of depressive symptoms and mortality remains poorly understood.

AIMS

To examine whether the duration of depressive symptoms is associated with mortality risk.

METHOD

Data (n= 9560) came from the English Longitudinal Study of Ageing (ELSA). We assessed depressive symptom duration as the sum of examinations with an eight-item Center for Epidemiologic Studies Depression Scale score of ⩾3; we ascertained mortality from linking our data to a national register.

RESULTS

Relative to those participants who never reported symptoms, the age- and gender-adjusted hazard ratios for elevated depressive symptoms over 1, 2, 3 and 4 examinations were 1.41 (95% CI 1.15-1.74), 1.80 (95% CI 1.44-2.26), 1.97 (95% CI 1.57-2.47) and 2.48 (95% CI 1.90-3.23), respectively (Pfor trend <0.001). This graded association can be explained largely by differences in physical activity, cognitive function, functional impairments and physical illness.

CONCLUSIONS

In this cohort of older adults, the duration of depressive symptoms was associated with mortality in a dose-response manner.

Depressive symptoms are doubled in older British South Asian and Black Caribbean people compared with Europeans: associations with excess co-morbidity and socioeconomic disadvantage

BACKGROUND

Despite elevated risk profiles for depression among South Asian and Black Caribbean people in the UK, prevalences of late-life depressive symptoms across the UK's three major ethnic groups have not been well characterized.

METHOD

Data were collected at baseline and 20-year follow-up from 632 European, 476 South Asian and 181 Black Caribbean men and women (aged 58-88 years), of a community-based cohort study from north-west London. The 10-item Geriatric Depression Scale was interviewer-administered during a clinic visit (depressive symptoms defined as a score of ⩾4 out of 10), with clinical data (adiposity, diabetes, cardiovascular disease, cognitive function) also collected. Sociodemographic, psychosocial, behavioural, disability, and medical history information was obtained by questionnaire.

RESULTS

Prevalence of depressive symptoms varied by ethnic group, affecting 9.7% of White European, 15.5% of South Asian, and 17.7% of Black Caribbean participants. Compared with White Europeans, South Asian and Black Caribbean participants were significantly more likely to have depressive symptoms (odds ratio 1.79, 95% confidence interval 1.24-2.58 and 1.80, 1.11-2.92, respectively). Adjustment for co-morbidities had most effect on the excess South Asian odds, and adjustment for socioeconomic position had most effect on the elevated Black Caribbean odds.

CONCLUSIONS

Higher prevalence of depressive symptoms observed among South Asian people were attenuated after adjustment for physical health, whereas the Black Caribbean increased prevalence was most explained by socioeconomic disadvantage. It is important to understand the reasons for these ethnic differences to identify opportunities for interventions to address inequalities.

Depression increases the onset of cardiovascular disease over and above other determinants in older primary care patients, a cohort study

Background

To determine if major depressive disorder (MDD) in older primary care patients is an independent risk factor for cardiovascular events.

Methods

A cohort of 143 primary care patients with depression and 139 non-depressed controls without depression (both aged over 55 years, matched for age and gender) from the Netherlands was evaluated for 2 years. MDD was diagnosed according to DSM-IV–criteria. During the follow-up period, information was collected on physical health, depression status and behavioural risk factors. CVD end points were assessed with validated annual questionnaires and were crosschecked with medical records.

Results

Thirty-four participants experienced a cardiovascular event, of which 71 % were depressed: 27/134 with MDD (20.1 %) and 9/137 controls (6.6 %). MDD was associated with a hazard ratio of 2.83 (p value 0,004, 95 % CI 1.32 to 6.05) for cardiovascular events. After adjustment for cardiovascular medication, the hazard ratio was 2.46 (95 % CI 1.14 to 5.30).

Conclusions

In a 2-year follow-up period, baseline MDD increased the risk for CVD in older primary care patients compared with controls, over and above well-known cardiovascular risk factors.

Consequences of interaction of functional, somatic, mental and social problems in community-dwelling older people

This study explores the combination of four common health problems in older people and whether problems on four domains result in an additional effect on indicators of poor health. For this purpose, a total of 2681 participants (32% male, mean age 82 years) of the Integrated Systematic Care for Older People (ISCOPE) study were screened on the presence of health problems on four domains (functional, somatic, mental, social) with the postal ISCOPE questionnaire. Extensive interview data on health indicators were obtained at baseline and at 12-months follow-up, including disability (Groningen Activities Restriction Scale, GARS), cognitive function (Mini-Mental State Examination, MMSE), depressive symptoms (Geriatric Depression Scale-15, GDS), loneliness (loneliness scale of De Jong Gierveld), and health-related quality of life (EQ-5D). General practitioner (GP) contact time (min/year) was estimated via GP electronic medical records. Of the study population, 9% had no health problems according to the screening, 8% had problems on one domain, 27% on two, 38% on three and 18% on four domains. At baseline, the number of health domains with problems was associated with poorer scores on the GARS, the MMSE, the GDS-15, the loneliness scale, the EQ-5D and with more GP contact time (p <0.001). Problems on all four domains had an additional negative effect on these health indicators (all p_interaction <0.001). At follow-up, an increased number of domains with problems was associated with an increased decline in health indicators (all p<0.001) and with an additional negative effect on GP contact time of the presence of problems on all four domains (p_interaction <0.001). We conclude that combinations of functional, somatic, mental and social problems are associated with poor health indicators in community-dwelling older people. Since problems on four domains have an additional effect on health, individuals with combined functional, somatic, mental and social problems could benefit from integrated care.

Self-transcendence, spiritual perspective, and sense of purpose in family caregiving relationships: a mediated model of depression symptoms in Korean older adults

OBJECTIVES

This study used structural equation modeling to test the mediated model of late-life depression to understand the mechanisms that account for the direct and indirect effects of spiritual variables and purpose in life on depression within the context of Korean family caregiving relationships.

METHOD

A secondary analysis study design used data from a study that tested a theory of family interdependence of 157 Korean elder-family caregiver dyads in Seoul, Korea.

RESULTS

Both caregivers' and elders' self-transcendence was positively related to their own sense of purpose in life. However, only elders' spiritual perspective was related to purpose in life. Also, elders' purpose in life was positively associated with caregivers' purpose in life. Furthermore, there was a strong negative relationship between elders' purpose in life and their depressive symptoms, but there was not a significant negative relationship between caregivers' purpose in life and elders' depressive symptoms. Last, elders' purpose in life mediated the negative effects of elders' self-transcendence and spiritual perspective and of caregivers' self-transcendence and purpose in life on elders' depression.

CONCLUSION

The findings suggest that purpose in life for both the caregiver and elder played an important role in elders' depression. Self-transcendence also was related to decreased depression in elders. It is suggested that more attention be given to caregiver and elder purpose in life in developing interventions to reduce or avoid elder depression in Korean elders.

Risk factors for depressive disorders in very old age: a population-based cohort study with a 5-year follow-up

PURPOSE

Depressive disorders are common among the very old, but insufficiently studied. The present study aims to identify risk factors for depressive disorders in very old age.

METHODS

The present study is based on the GERDA project, a population-based cohort study of people aged ≥85 years (n = 567), with 5 years between baseline and follow-up. Factors associated with the development of depressive disorders according to DSM-IV criteria at follow-up were analysed by means of a multivariate logistic regression.

RESULTS

At baseline, depressive disorders were present in 32.3 % of the participants. At follow-up, 69 % of those with baseline depressive disorders had died. Of the 49 survivors, 38 still had depressive disorders. Of the participants without depressive disorders at baseline, 25.5 % had developed depressive disorders at follow-up. Baseline factors independently associated with new cases of depressive disorders after 5 years were hypertension, a history of stroke and 15-item Geriatric Depression Scale score at baseline.

CONCLUSIONS

The present study supports the earlier findings that depressive disorders among the very old are common, chronic and malignant. Mild depressive symptoms as indicated by GDS-15 score and history of stroke or hypertension seem to be important risk factors for incident depressive disorders in very old age.

[Anxiety and depression in the elderly]

OBJECTIVES

This paper deals with diagnostics and prevalence of depression and anxiety in the elderly, their biological, psychological, and social risk factors, and the effectiveness of psychotherapy and pharmacotherapy.

METHODS

The results are based on an overview of the literature reflecting reviews and meta-analyses.

RESULTS

In the elderly, there is a substantial danger of confounding psychogenic with medical or drug-induced symptoms. Self-assessment scales may be useful for screening, but the results should be confirmed by an expert interview. Based on the available research, we cannot yet be sure whether the prevalence of depression and anxiety in the elderly population is in fact higher, lower, or equal to younger age groups. More women are afflicted with depression or anxiety than men. Pharmacotherapy (preferably antidepressants) and psychotherapy are effective for treating anxiety and depression in the elderly, with medium to high effect sizes. To date it is not possible to provide evidence-based treatment recommendations for the type or the setting of psychotherapy.

DISCUSSION

More research on this topic is needed.

[Depression in the elderly: prevalence and associated factors]

AIM

To determine the prevalence of depression, and to study the factors associated with it among community-dwelling 85-year-olds.

MATERIAL AND METHODS

A cross-sectional study was conducted within the framework of a randomized clinical trial in elderly people, all born in 1924, from seven urban and rural primary health care centers. Sociodemographic data and geriatric assessment were performed. Functional status was measured with Barthel index and Lawton index, cognitive impairment with Mini-mental Status Examination, social risk with Gijon test, and comorbidity by Charlson index. The presence of exhaustion and physical activity were recorded along with the chronic prescription of psycothropic drugs, and the presence of depression in clinical registers. Depression was evaluated using the Yesavage Geriatric Depression Scale (GDS) of 5 items (depression ≥ 2). The statistical program used was the R project: (version 2.12.2) Foundation for Statistical Computing, Vienna.

RESULTS

The sample was consisted of 220 subjects, 129 women (58.6%), 76 (34.5% were depressed using the GDS, 46 (20.9%) subjects had depression in the clinical records, and 60 (35.5%) patients were taking antidepressant drugs, 66 (36,8%) benzodiazepine, and 10 (4%) antipsychotic drugs. Depression was associated with poorer functional status according to basic and instrumental activities of daily living, cognitive impairment, exhaustion, low physical activity, and psychotropic drugs. Finally, the factors significantly associated with depression were low physical activity and increased exhaustion.

CONCLUSIONS

The present study found a high prevalence of depression in subjects older than 85 years. Physical activity and having a good self-perception of energy are associated to a lower prevalence of depression.

Depressed mood and cause-specific mortality: a 40-year general community assessment

PURPOSE

The current study describes how the excess mortality risk associated with depression translates into specific causes of death occurring during a 40-year follow-up period, with focus on deaths related to injuries, cardiovascular diseases, and cancer.

METHODS

Data come from a cross-sectional survey (Community Mental Health Epidemiology Study) conducted in the early 1970s in Washington County, Maryland. Random sampling for the survey resulted in 2762 interviews. For the current analyses, baseline depressed mood was linked to current participant vital status through the use of death certificates.

RESULTS

The relative subdistribution hazards for cardiovascular deaths (3.08 [1.74-5.45]) and fatal injuries (4.63 [1.76-12.18]) were significant during the entire 40-year period for young adults (18-39 years old at baseline). The relative subdistribution hazard for cardiovascular deaths during the first 15 years of follow-up was pronounced in elderly (≥ 65 years) males (2.99 [1.67-5.37]) subjects. There were no significant associations between depressed mood and cancer deaths.

CONCLUSIONS

Individuals in the general community with depressed mood may be at increased risk of deaths as the result of cardiovascular disease and injury, even several decades after exposure assessment. Young adults with depressed mood appear to be particularly vulnerable to these associations.

The contribution of depression to mortality among elderly with self-reported hypertension: analysis using a national representative longitudinal survey

OBJECTIVE

Previous research has suggested that hypertension and depression are two of the important causes of mortality among the elderly. This study aims to test the contribution of depression to mortality among elderly with self-reported hypertension.

METHODS

This research used data from the Survey of Health and Living Status of the Middle Age and Elderly (SHLS) conducted by the Bureau of Health Promotion, Department of Health in Taiwan. The 1989, 1996, 1999, 2003, and 2007 waves were used. In total, 3736 respondents aged 60 or above were analyzed. Participants were grouped by status of hypertension and depression. The contribution of depression to mortality among elderly with self-reported hypertension was estimated using Cox proportional hazard model. Analyses were separated into younger elderly individuals (<70 years) and older elderly individuals (≥ 70 years).

RESULTS

In the full model, the hazard ratios for mortality for the groups of not hypertensive/depressed, hypertensive/not depressed, and hypertensive/depressed were 1.12 [95% confidence interval (CI) 0.98-1.28], 1.32 (95% CI 1.19-1.46), and 1.54 (95% CI 1.29-1.83), respectively, compared with the reference group of not hypertensive/not depressed. The pattern remained the similar after separating the participants into the two age groups. However, much higher hazard ratios were observed for the older cohort.

CONCLUSION

Depression contributes significantly to the hypertension-mortality relationship for the elderly. For the elderly, hypertension should be tackled along with depression in order to reduce the mortality associated with hypertension.

Indicators of material hardship and depressive symptoms among homebound older adults living in North Carolina

This study used the concept of material hardship to understand how unmet needs related to food, housing, and health influence depressive symptoms among homebound older adults (N = 345) in North Carolina. Using data from the Nutrition and Function Study, 37% reported high levels of depressive symptoms and 17.4% indicated not receiving needed health care. Approximately 10% of respondents were food insecure; 30.7% were at risk for food insecurity; and 39.7% reported having to choose between either food and medication or food and paying bills. Adjusted logistic regression model revealed that food insecurity status (OR = 4.9) and age 60-74 y (OR = 2.4) were significantly associated with a greater number of depressive symptoms. Other indicators of material hardship, such as having a major financial difficulty, unmet health need, and inadequate housing, were not significant. By far, food insecurity was the most salient influence on depressive symptoms. These findings have important implications for service providers, researchers, and policymakers.

Late life depression and incident activity limitations: influence of gender and symptom severity

BACKGROUND

Mental disorders, especially depression, are one of the principal causes of disablement. Previous research has been limited partly due to the failure to take into account sub-syndromal states and the very large number of candidate mediating and confounding factors.

METHODS

Longitudinal associations between baseline depressive symptomatology and activity limitations were examined in a community-dwelling elderly cohort of 3191 participants. Mixed logistic models were used to determine associations between mild or severe depressive symptoms (Center for Epidemiologic Studies-Depression Scale, CES-D), and 7-year incident disability on four limitation scales assessing instrumental and basic activities of daily living, mobility using the Rosow and Breslau scale, and social restriction.

RESULTS

In men, mild depressive symptomatology was associated with increased incident limitations on instrumental activities of daily living (IADL) (odds ratio (OR) (95% CI)=5.07 (2.25-11.42)). In women, severe depressive symptomatology was related to social restriction (OR (95% CI)=2.36 (1.31-4.25)), IADL (OR (95% CI)=1.89 (1.13-3.15)) and activities of daily living (OR (95% CI)=11.15 (3.43-36.23)). Men and women with a 2-year increase in CES-D score were highly at risk for social restriction and limitations in mobility and IADL.

CONCLUSION

Depression is an independent predictor of disability in the elderly population; the relation is gender-dependent and varies with symptom load.

Factors Influencing Risk of Premature Mortality in Community Cases of Depression: A Meta-Analytic Review

Background. Depressive disorders are associated with substantial risk of premature mortality. A number of factors may contribute to reported risk estimates, making it difficult to determine actual risk of excess mortality in community cases of depression. The aim of this study is to conduct a systematic review and meta-analysis of excess mortality in population-based studies of clinically defined depression. Methods. Population-based studies reporting all-cause mortality associated with a clinically defined depressive disorder were included in the systematic review. Estimates of relative risk for excess mortality in population-representative cases of clinical depressive disorders were extracted. A meta-analysis was conducted using Stata to pool estimates of excess mortality and identify sources of heterogeneity within the data. Results. Twenty-one studies reporting risk of excess mortality in clinical depression were identified. A significantly higher risk of mortality was found for major depression (RR 1.92 95% CI 1.65–2.23), but no significant difference was found for dysthymia (RR 1.37 95% CI 0.93–2.00). Relative risk of excess mortality was not significantly different following the adjustment of reported risk estimates. Conclusion. A mortality gradient was identified with increasing severity of clinical depression. Recognition of depressive symptoms in general practice and appropriate referral for evidence-based treatment may help improve outcomes, particularly in patients with comorbid physical disorders.

Depression, nutritional risk and eating behaviour in older caregivers

OBJECTIVE

This study investigated the relationship between depression, nutritional risk and dietary intake in a population of older caregivers.

DESIGN

Mailed questionnaire with sub group participating in a home-based interview.

PARTICIPANTS AND SETTING

Seventy-six community dwelling caregivers aged 50 y or over from Victoria, Australia.

MEASUREMENTS

Questionnaires provided information on weight, height, hours of care, depressive symptoms, nutritional risk and appetite. The home-based interview assessed dietary intake and shopping, cooking and meal consumption habits.

RESULTS

The sample had a mean +/- SD age of 70.3 +/- 12.8 y, BMI of 27.2 +/- 4.8 kg/m2 and the time spent caring was 101.8 +/- 68.1 h/wk. Overall, 32% of caregivers had depressive symptoms, 21% were at risk of malnutrition and 21% reported their appetite was fair/bad/very bad. Caregivers with depressive symptoms (32%) compared to those with no depressive symptoms (53%) had a poorer appetite (p < 0.05). Of the 20 caregivers who participated in the home interview, 25% reported they ate their meals alone.

CONCLUSION

A significant proportion of community dwelling older caregivers had depressive symptoms, were at risk of malnutrition and had poor appetites, although the majority were overweight or obese.

Co-occurrence of depression and anxiety in elderly subjects aged 90 years and its relationship with functional status, quality of life and mortality

OBJECTIVE

To examine the prevalence of concurrent depression and anxiety and its relationship with functional status, quality of life and mortality in individuals at age 90.

METHODS

In the Leiden 85-plus Study, a population based cohort study, depression (15-item Geriatric Depression Scale >or=5 points) and anxiety (Anxiety Screening Questionnaire >or=1 positive answer) were assessed in all 90-year old subjects with >or=19 points on the Mini Mental State Examination (MMSE). Functional status included: cognitive function (MMSE) and disability in activities of daily living (Groningen Activity Restriction Scale). Quality of life included: loneliness (Loneliness Scale of De Jong-Gierveld) and life satisfaction (Cantril's ladder). For all subjects mortality data were available up to a maximum age of 95.3 years.

RESULTS

Of the subjects aged 90 years with MMSE >or=19 points (56 men, 145 women), 50 subjects (25%, 95% CI 19-31%) experienced depression and 25 subjects (12%, 95% CI 9-18%) anxiety; of them 34 (17%) experienced depression only, 9 (4%) anxiety only, and 16 (8%) both depression and anxiety. Presence of depression was associated with an overall decreased functional status and quality of life and with increased mortality. Within the depressed group, subjects with anxiety did not differ from subjects without anxiety, except for higher loneliness scores.

CONCLUSION

Among individuals aged 90 years, depression and anxiety and their co-occurrence are highly prevalent. Anxiety does not add to poor functional status and increased mortality beyond that associated with depression, and is probably part of the phenomenology of depression in old age.

The oldest old in England and Wales: a descriptive analysis based on the MRC Cognitive Function and Ageing Study

OBJECTIVE

to describe the characteristics and survival of the oldest old in England and Wales.

DESIGN

retrospective analysis of the oldest old from a population-based cohort study.

SETTING

population-based study in England and Wales: two rural and three urban sites.

METHODS

two types of analyses were conducted: (i) a descriptive analysis of those individuals who were aged 90 years or more, and 100 years or more, and (ii) a survival analysis of those who reached their 90th, 95th, or 100th birthday during the study. Median survival time was calculated by the Kaplan-Meier method. Effects of socio-demographic characteristics on survival were evaluated using the Cox proportional-hazards regression model.

RESULTS

in total, 958 individuals aged 90 years or more, and 24 individuals aged 100 years or more, had been interviewed at least once during the study. Twenty-seven per cent were living in residential or nursing homes. Women aged 90 years or more were more likely to be living in residential and nursing homes, be widowed, have any disability or have lower MMSE scores. The centenarians were mostly cognitively and functionally impaired. The median survival times for those reaching their 90th (n = 2,336), 95th (n = 638), or 100th birthday (n = 92) during the study were 3.7 years (95% CI: 3.5-4.0), 2.3 (2.1-2.6) and 2.1 (1.7-2.6) years for women, and 2.9 (95% CI: 2.6- 3.1), 2.0 (1.2-3.1) and 2.2 (0.5-2.3) for men, respectively. Those living in residential and nursing homes had a shorter survival when aged 90 years, with similar non-significant effects for those aged 95 and 100 years. After the age of 100 years, the high mortality rate and small sample size limited the ability to detect any differences between the different groups.

CONCLUSION

even at the very oldest ages, the majority live in non-institutionalised settings. Among the oldest old, women were frailer than men. Being male and living in residential nursing homes shortened survival in those aged 90 years or more.

Late-life depression and mortality: influence of gender and antidepressant use

BACKGROUND

Depression may increase the risk of mortality among certain subgroups of older people, but the part played by antidepressants in this association has not been thoroughly explored.

AIMS

To identify the characteristics of older populations who are most at risk of dying, as a function of depressive symptoms, gender and antidepressant use.

METHOD

Adjusted Cox proportional hazards models were used to determine the association between depression and/or antidepressant use and 4-year survival of 7,363 community-dwelling elderly people. Major depressive disorder was evaluated using a standardised psychiatric examination based on DSM-IV criteria and depressive symptoms were assessed using the Center for Epidemiological Studies-Depression scale.

RESULTS

Depressed men using antidepressants had the greatest risk of dying, with increasing depression severity corresponding to a higher hazard risk. Among women, only severe depression in the absence of treatment was significantly associated with mortality.

CONCLUSIONS

The association between depression and mortality is gender-dependent and varies according to symptom load and antidepressant use.

Survival rate and causes of mortality in the elderly with depression: a 15-year prospective study of a Japanese community sample, the Matsunoyama-Niigata suicide prevention project

OBJECTIVE

To compare long-term survival rates and causes of death in community-dwelling elderly with and without depression using the International Research Diagnostic Criteria administered by a psychiatrist.

METHOD

From 1985 to 2000, we prospectively examined Japanese persons (N = 920) aged 65 years or older. Cases with depression (n = 158) and a control sample without depression (N = 762) were evaluated. The main outcome variables were survival rates and causes of mortality.

RESULTS

By 2000, 61% of the subjects with depression had died. By contrast, 48% had died in the control group at the completion of the 15-year follow-up. Using age-adjusted Kaplan-Meier survival analysis, we found a hazard ratio (HR) of 1.49 (95% confidence interval [CI] 1.16-1.89) for mortality in the depressed group compared with controls (p = .0009). Importantly, in female subjects with depression, the HR was 1.55 (95% CI 1.16-2.07; p = .002). In males with depression, by contrast, the HR (1.34) was not significant (95% CI 0.84-2.13; p = .19). Significantly more subjects died of cerebrovascular disorders, malignant tumors, respiratory disorders, or suicide after the onset of depression compared with controls (p < .05).

CONCLUSIONS

Depression appears to be associated with a significant increase in the risk of mortality among elderly Japanese subjects, particularly in females. The elderly with a diagnosis of depression may be at an elevated risk of mortality owing to cerebrovascular disorder, malignant tumors, respiratory disorders, or suicide. These prospective data provide a new quantitative insight on gender differences and the long-term public health significance of depression among the community-dwelling elderly.

Depression and the risk for cardiovascular diseases: systematic review and meta analysis

BACKGROUND

Depression and cardiovascular diseases are both common among elderly. Depression is suspected to be an independent risk factor for the onset of coronary heart disease, yet it is not clear to what extent and if depression also is associated with the onset of other diseases of the circulatory system.

AIMS

To estimate the risk of depression as an independent risk factor for various cardiovascular diseases (CVD) and explore the effects of heterogeneity and methodological quality.

METHOD

Meta-analyses and meta-regression analyses of longitudinal cohort and case-control studies reporting depression at baseline and CVD outcomes at follow-up.

DATA SOURCES

MEDLINE (1966-2005) and PSYCHINFO (1966-2005).

RESULTS

Of the 28 studies that met the inclusion criteria, 11 were assesed as high quality studies. Although depressed mood increased the risk for a wide range of CVDs, heterogeneity was substantial in most cases. Only the overall combined risk of depression for the onset of myocardial infarctions (n=8, OR=1.60, 95%CI 1.34-1.92) was homogenous. Clinically diagnosed major depressive disorder was identified as the most important risk factor for developing CVD.

CONCLUSIONS

Depression seems to be an independent risk factor for the onset of a wide range of CVDs, although this evidence is related to a high level of heterogeneity.

Recent evidence linking coronary heart disease and depression

OBJECTIVES

To review the recent literature on the relation between depression and coronary heart disease (CHD), including both etiologic studies (that is, depression preceding development of CHD) and prognostic studies (that is, depression predicting prognosis in established CHD), and to assess the degree to which the literature supports a causal interpretation of the link between depression and CHD.

METHOD

We searched the MEDLINE, Current Contents, and PsycINFO databases for articles published between December 15, 2003, and December 15, 2005, containing combinations of several key words related to CHD, prognosis, and depression. We reviewed papers for evidence of 6 rule-of-thumb criteria for making causal inferences: objective CHD outcome measures, prospective designs, results showing consistent and strong dose-response relations, adequate covariate adjustment, biological plausibility, and evidence from clinical trials that changing depression alters CHD risk.

RESULTS

We found 8 recent etiologic studies, 16 prognostic studies, 2 publications with both types of data, and 23 review papers. Although there was much methodological variability concerning measurement of depression and assessment of cardiac outcomes, the recent etiologic studies increase the evidence of a role for depression. Recent prognostic data are less consistent. Small studies showing no link between depression and CHD prognosis continue to appear, despite lack of adequate statistical power.

CONCLUSIONS

The recent literature continues to support both an etiologic and a prognostic role for depression in CHD. Despite this evidence, there have been few clinical trials of depression treatment in CHD patients and no clinical trials of depression prevention. Additional trials are needed.

Depression and adipose and serum cholesteryl ester polyunsaturated fatty acids in the survivors of the seven countries study population of Crete

BACKGROUND

Studies have shown that depression relates to biomarkers of both short- and long-term polyunsaturated fatty acid (PUFA) intake. However, it is not known which of these two biomarkers has the closest relationship to depression.

OBJECTIVE

To examine the relationship of depression with both adipose tissue and serum cholesteryl ester PUFA and to assess the importance of each of these two biomarkers in relating to depression.

DESIGN

Cross-sectional study of healthy elderly men from the island of Crete.

SETTING

The Preventive Medicine and Nutrition Clinic, University of Crete, Greece.

SUBJECTS

A total of 150 males, aged 80-96 years. The subjects were survivors of the Greek Seven Countries Study group.

METHODS

Fatty acids were determined by gas chromatography in adipose tissue and serum cholesteryl esters. Information about depression was obtained through the use of the short form of the Geriatric Depression Scale (GDS-15).

RESULTS

Regression analysis showed that depression related positively to age and serum cholesteryl ester arachidonic/docosahexaenoic fatty acid ratio. The only significant unadjusted correlation between depression and serum cholesteryl ester and adipose fatty acids was with adipose alpha-linolenic acid (ALA) (r = -0.31, P < 0.01). Depressed males (GDS-15 > 5) had lower adipose ALA and sum n-3 fatty acids than non-depressed ones. There were no significant differences between depressed and non-depressed males in serum cholesteryl ester fatty acids. When adipose tissue ALA was included as one of the independent measures in the regression model, the observed positive relation between GDS-15 depression and cholesteryl ester arachidonic/docosahexaenoic ratio failed to persist. Instead, there was a negative relationship between GDS-15 depression and adipose tissue ALA.

CONCLUSIONS

It appears that the fatty acids of the adipose tissue are better predictors of depression than those of serum cholesteryl esters. This indicates that depression relates more strongly to long-term than to short-term fatty acid intake. The reason for this may be the reported slow rate of deposition of dietary PUFA to the brain.

Marriage and mortality in bladder carcinoma

BACKGROUND

Being married confers significant benefits in survival for patients with a variety of chronic conditions including breast and prostate carcinoma. The authors attempted to determine whether marital status is associated with survival in patients undergoing radical cystectomy for bladder carcinoma.

METHODS

The authors identified 7262 subjects from the Surveillance, Epidemiology, and End Results public-use database who underwent radical cystectomy for transitional cell carcinoma of the bladder. They performed survival analyses using Kaplan-Meier estimates and Cox proportional hazards models. The authors created multivariate models to evaluate the independent association between marital status and survival, controlling for pathologic stage, lymph node status, age, race/ethnicity, and gender.

RESULTS

Married subjects were older and more often male, white, and had earlier disease stage at diagnosis. Married subjects had significantly better survival than did single or widowed subjects (P < 0.001), and married subjects revealed a trend toward better survival than separated/divorced subjects (P = 0.20). Multivariate modeling revealed that compared with single subjects, those who were married had better survival, independent of age at the time of diagnosis, gender, race/ethnicity, disease stage, and lymph node status (P < 0.001).

CONCLUSIONS

Marriage was associated with improved survival in patients with bladder carcinoma, independent of other factors known to influence mortality in this population. Although the mechanisms underlying this survival advantage are unknown, possibilities include differences in cancer screening, risk behaviors, and access to medical care. The interaction between psychosocial factors and the body's immune function may further explain the differential survival in this cohort.