The role of persistent and incident major depression on rate of cognitive deterioration in newly diagnosed Alzheimer's disease patients

Rumination in dementia and its relationship with depression, anxiety, and attentional biases

Rumination (self-referential and repetitive thinking), attentional biases (AB), and impaired cognitive control are theorized as being integral factors in depression and anxiety. Yet, research examining the relationship between rumination, mood, and AB for populations with reduced cognitive control, e.g., people living with dementia (PwD), is lacking. To explore whether literature-based relationships are demonstrated in dementia, PwD (n = 64) and healthy controls (HC) (n = 75) completed an online self-report survey measuring rumination and mood (twice), and a telephone cognitive status interview (once). Rumination was measured as an emotion-regulation style, thinking style, and response to depression. We examined the test-retest reliability of PwD's (n = 50) ruminative-scale responses, ruminative-scale internal consistency, and correlations between rumination, age, cognitive ability, and mood scores. Also, nine participants (PwD = 6, HC = 3) completed an AB measure via eye-tracking. Participants fixated on a cross, naturally viewed pairs of facial images conveying sad, angry, happy, and neutral emotions, and then fixated on a dot. Exploratory analyses of emotional-face dwell-times versus rumination and mood scores were conducted. Except for the HC group's reflective response to depression measure, rumination measures were reliable, and correlation strengths between rumination and mood scores (.29 to .79) were in line with literature for both groups. For the AB measure subgroup, ruminative thinking style scores and angry-face metrics were negatively correlated. The results of this study show that literature-based relationships between rumination, depression, and anxiety are demonstrated in dementia, but the relationship between rumination and AB requires further investigation.

Prognostic and Predictive Factors in Early Alzheimer's Disease: A Systematic Review

Background

Alzheimer's disease (AD) causes progressive decline of cognition and function. There is a lack of systematic literature reviews on prognostic and predictive factors in its early clinical stages (eAD), i.e., mild cognitive impairment due to AD and mild AD dementia.

Objective

To identify prognostic factors affecting eAD progression and predictive factors for treatment efficacy and safety of approved and/or under late-stage development disease-modifying treatments.

Methods

Databases were searched (August 2022) for studies reporting prognostic factors associated with eAD progression and predictive factors for treatment response. The Quality in Prognostic Factor Studies tool or the Cochrane risk of bias tool were used to assess risk of bias. Two reviewers independently screened the records. A single reviewer performed data extraction and quality assessment. A second performed a 20% check. Content experts reviewed and interpreted the data collected.

Results

Sixty-one studies were included. Self-reporting, diagnosis definition, and missing data led to high risk of bias. Population size ranged from 110 to 11,451. Analyses found data indicating that older age was and depression may be associated with progression. Greater baseline cognitive impairment was associated with progression. APOE4 may be a prognostic factor, a predictive factor for treatment efficacy and predicts an adverse response (ARIA). Elevated biomarkers (CSF/plasma p-tau, CSF t-tau, and plasma neurofilament light) were associated with disease progression.

Conclusions

Age was the strongest risk factor for progression. Biomarkers were associated with progression, supporting their use in trial selection and aiding diagnosis. Baseline cognitive impairment was a prognostic factor. APOE4 predicted ARIA, aligning with emerging evidence and relevant to treatment initiation/monitoring.

Investigation of Potential Drug Targets Involved in Inflammation Contributing to Alzheimer's Disease Progression

Alzheimer's disease has become a major public health issue. While extensive research has been conducted in the last few decades, few drugs have been approved by the FDA to treat Alzheimer's disease. There is still an urgent need for understanding the disease pathogenesis, as well as identifying new drug targets for further drug discovery. Alzheimer's disease is known to arise from a build-up of amyloid beta (Aβ) plaques as well as tangles of tau proteins. Along similar lines to Alzheimer's disease, inflammation in the brain is known to stem from the degeneration of tissue and build-up of insoluble materials. A minireview was conducted in this work assessing the genes, proteins, reactions, and pathways that link brain inflammation and Alzheimer's disease. Existing tools in Systems Biology were implemented to build protein interaction networks, mainly for the classical complement pathway and G protein-coupled receptors (GPCRs), to rank the protein targets according to their interactions. The top 10 protein targets were mainly from the classical complement pathway. With the consideration of existing clinical trials and crystal structures, proteins C5AR1 and GARBG1 were identified as the best targets for further drug discovery, through computational approaches like ligand-protein docking techniques.

Webcam-Based Eye-Tracking of Attentional Biases in Alzheimer's Disease: A Proof-Of-Concept Study

OBJECTIVES

To measure home-based older adults' attentional biases (AB) using webcam-based eye-tracking (WBET) and examine internal consistency.

METHODS

Twelve participants with and without cognitive impairment completed online self-report anxiety and depression screens, and a 96-trial dot-probe task with eye-gaze tracking. For each trial, participants fixated on a cross, free-viewed sad-neutral, sad-angry, sad-happy, angry-neutral, angry-happy, and happy-neutral facial expression pairings, and then fixated on a dot. In emotional-neutral pairings, the time spent looking (dwell-time) at neutral was averaged and subtracted from the emotional average to indicate biases "away from" (negative score) and "toward" (positive score) each emotional face. Internal consistency was estimated for dwell-times and bias scores using Cronbach's alpha and Spearman - Brown corrected split-half coefficients.

RESULTS

The full-cohort and a comorbid anxious and depressed sub-group (n = 6) displayed AB away from sad faces, and toward angry and happy faces, with happy-face AB being more pronounced. AB indices demonstrated low reliability except sub-group happy-face indices. Happy-face AB demonstrated the highest reliability.

CONCLUSIONS

AB measures were in-line with lab-based eye-tracking literature, providing some support for WBET-based measurement.

CLINICAL IMPLICATIONS

Establishing the feasibility of WBET-based measures is a step toward an objective home-based clinical tool. Literature-based suggestions are provided to improve reliability.

The impact of depression on language function in individuals with Alzheimer's disease: a pre/post-treatment design

BACKGROUND

It is uncertain whether depression might affect cognitive function in Alzheimer's disease (AD). Most of studies on the effect of depression treatment on cognitive function in AD were briefly evaluated by Mini-Mental State Examination (MMSE). MMSE is poor sensitive to detect cognitive change. This study examined the cognitive response to depression treatment in AD via multi-domain assessment. In addition, we explored whether effect of depression treatment in AD is different those of late-life depression (LLD).

METHODS

This study include AD patients with depression (AD + D) and without depression (AD - D), LLD patients (LLD), and healthy controls (HC). The patients were treated according to their diagnosis for 16 weeks: acetylcholinesterase inhibitors (AChEIs) and selective serotonin reuptake inhibitors (SSRIs) for AD + D, AChEIs for AD - D, and SSRIs for LLD. The cognitive changes from pre- to post-treatment were compared between AD + D and AD - D or LLD and HC. An independent sample t test was performed to compare the degree of change between the groups. Paired t tests were used to determine cognitive function changes in each depression treatment responder group.

RESULTS

At baseline, AD + D had more impairment in language function compared to AD - D, and LLD had greater deficit in executive function than HC. After depression treatment, more impaired cognitive domains at baseline were improved in AD + D and LLD, respectively. Moreover, AD + D showed an improvement in the global cognitive function (MMSE).

CONCLUSIONS

Results indicated that language function was influenced by depression in AD, which is first evidence for specific cognitive domain related to depression in AD. Our finding indicates that depression could negatively impact cognitive function, and depression treatment may have beneficial cognitive effect in both AD and LLD. This study suggests the importance of early detection and treatment of depression in AD and LLD. Trial registration Clinical Research Information Service, CRIS, ID#: KCT0004041, Registered 5 June 2019, retrospectively registered after first patient enrollment date (4 March 2014) https://cris.nih.go.kr/cris/search/detailSearch.do?seq=14140&status=5&seq_group=14140&search_page=M .

Relationship among number of close friends, subclinical geriatric depression, and subjective cognitive decline based on regional homogeneity of functional magnetic resonance imaging data

The relationship between geriatric depression and dementia has been widely debated, and the neurological mechanisms underlying subjective cognitive decline (SCD) associated with social relationships remain elusive. Subclinical geriatric depression (SGD) is common in patients with SCD, and close friends (CFs) have a great influence on a person's social life. Studies have proven that communication or leisure activities with CFs can improve the cognitive performance of elderly. However, it remains unclear whether the engagement of specific brain regions mediates having CFs, SGD, and SCD. In this study, we aimed to assess the association between social relationships (that is, CFs), SGD, and SCD from the perspective of brain function. We examined the data of 66 patients with SCD and 63 normal controls (NC). Compared with NC, SGD was significantly inversely correlated with the number of CFs in the SCD group. We calculated regional homogeneity (ReHo) of functional magnetic resonance imaging (MRI) data of each subject. At a corrected threshold, the right occipital gyrus (SOG.R) and right fusiform gyrus (FFG.R) exhibited positive correlation with SGD in patients with SCD. Mediation analyses to query the inter-relationships between the neural markers and clinical variables exhibited a best fit of the model with CFs → FFG.R → SGD → SOG.R → SCD. These findings suggested a pathway whereby social relationships alter the function of specific brain regions, and SGD may be an early symptom of SCD. We observed that the FFG.R mediate social relationships and SGD, and the abnormality of the SOG.R may be a key factor in the SCD caused by depression. Moreover, a greater number of CFs may reduce the risk of developing SGD.

Anxiety and depression in Alzheimer's disease: a systematic review of pathogenetic mechanisms and relation to cognitive decline

Objectives

To explore the pathogenetic hypothesis provided to explain the comorbidity of anxious and depressive symptomatology and AD and to assess the association between anxious and depressive symptoms and the AD-related cognitive impairment.

Methods

In October 2020 and March 2021, PsycINFO, Embase, Ovid, and CINAHL were searched for peer-reviewed original articles investigating anxiety and/or depression in AD.

Results

A total of 14,760 studies were identified and 34 papers on AD patients were included in the review. Suggested biological causes of depression and anxiety in AD include higher strychnine-sensitive glycine receptor (GlyRS) functioning and selective reduction of N-methyl-d-aspartate (NMDA) receptor NR2A density, cortical and limbic atrophy, lower resting cortical metabolism, lower CSF Aβ42 and higher t-tau and p-tau levels, and neuritic plaques. At the same time, dysthymia arises in the early stages of AD as an emotional reaction to the progressive cognitive decline and can cause it; anxiety can appear as an initial compensating behaviour; and depression might be related to AD awareness and loss of functional abilities. Affective symptoms and the expression of the depressive symptoms tend to reduce as AD progresses.

Conclusion

The neurodegeneration of areas and circuits dealing with emotions can elicit anxiety and depression in AD. In the early stages of the disease, anxiety and depression could arise as a psychological reaction to AD and due to coping difficulties. In late AD stages, the cognitive impairment reduces the emotional responses and their expression. Anxiety and depression are more intense in early-onset AD, due to the major impact of AD on the individual.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10072-022-06068-x.

Inflammation, negative affect, and amyloid burden in Alzheimer's disease: Insights from the kynurenine pathway

BACKGROUND

Depressive symptoms in Alzheimer's disease (AD) predict worse cognitive and functional outcomes. Both AD and major depression inflammatory processes are characterized by shunted tryptophan metabolism away from serotonin (5-HT) and toward the neuroinflammatory kynurenine (Kyn) pathway. The present study assessed associations between Kyn and behavioral, neuroanatomical, neuropathological, and physiological outcomes common to both AD and negative affect across the AD continuum.

METHODS

In 58 cognitively normal, 396 mild cognitive impairment, and 112 AD participants from the Alzheimer's Disease Neuroimaging Initiative-1 (ADNI1) cohort, serum markers of 5-HT, tryptophan, and Kyn were measured and their relationships investigated with immunologic markers, affect and functional outcomes, CSF markers of beta-amyloid (Aβ) and tau, and regional gray matter.

RESULTS

A higher Kyn/Tryptophan ratio was linked to many inflammatory markers, as well as lower functional independence and memory scores. A higher Kyn/5-HT ratio showed similar associations, but also strong relationships with negative affect and neuropsychiatric disturbance, executive dysfunction, and global cognitive decline. Further, gray matter atrophy was seen in hippocampus, anterior cingulate, and prefrontal cortices, as well as greater amyloid and total tau deposition. Finally, using moderated-mediation, several pro-inflammatory factors partially mediated Kyn/5-HT and negative affect scores in participants with subclinical Aβ (i.e., Aβ-), whereas such associations were fully mediated by Complement 3 in Aβ+ participants.

CONCLUSION

These findings suggest that inflammatory signaling cascades may occur during AD, which is associated with increased Kyn metabolism that influences the pathogenesis of negative affect. Aβ and the complement system may be critical contributing factors in this process.

Vitamin K2 Holds Promise for Alzheimer's Prevention and Treatment

Recent studies have highlighted the importance of vitamin K2 (VK2) in human health. However, there have been no clinical studies investigating the role of VK2 in the prevention or treatment of Alzheimer's disease (AD), a debilitating disease for which currently there is no cure. In reviewing basic science research and clinical studies that have connected VK2 to factors involved in AD pathogenesis, we have found a growing body of evidence demonstrating that VK2 has the potential to slow the progression of AD and contribute to its prevention. In our review, we consider the antiapoptotic and antioxidant effects of VK2 and its impact on neuroinflammation, mitochondrial dysfunction, cognition, cardiovascular health, and comorbidities in AD. We also examine the link between dysbiosis and VK2 in the context of the microbiome's role in AD pathogenesis. Our review is the first to consider the physiological roles of VK2 in the context of AD, and, given the recent shift in AD research toward nonpharmacological interventions, our findings emphasize the timeliness and need for clinical studies involving VK2.

Modifiable, Non-Modifiable, and Clinical Factors Associated with Progression of Alzheimer's Disease

There is an extensive literature relating to factors associated with the development of Alzheimer's disease (AD), but less is known about factors which may contribute to its progression. This review examined the literature with regard to 15 factors which were suggested by PubMed search to be positively associated with the cognitive and/or neuropathological progression of AD. The factors were grouped as potentially modifiable (vascular risk factors, comorbidities, malnutrition, educational level, inflammation, and oxidative stress), non-modifiable (age at clinical onset, family history of dementia, gender, Apolipoprotein E ɛ4, genetic variants, and altered gene regulation), and clinical (baseline cognitive level, neuropsychiatric symptoms, and extrapyramidal signs). Although conflicting results were found for the majority of factors, a positive association was found in nearly all studies which investigated the relationship of six factors to AD progression: malnutrition, genetic variants, altered gene regulation, baseline cognitive level, neuropsychiatric symptoms, and extrapyramidal signs. Whether these or other factors which have been suggested to be associated with AD progression actually influence the rate of decline of AD patients is unclear. Therapeutic approaches which include addressing of modifiable factors associated with AD progression should be considered.

Associations Between Neighborhood Park Access and Longitudinal Change in Cognition in Older Adults: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Preliminary evidence suggests associations between neighborhood park access and better late-life cognition and reduced Alzheimer's disease (AD) risk.

OBJECTIVE

Examine associations between neighborhood park access and longitudinal change in cognition among U.S. older adults without dementia.

METHODS

We used 2000-2018 observational data from the population-based, multi-site Multi-Ethnic Study of Atherosclerosis (n = 1,733). Measures included proportion of neighborhood park space (park access), distance to nearest park, and 6-year dichotomous and continuous change in scores on the Cognitive Abilities Screening Instrument (CASI; global cognition) and Digit Symbol Coding task (processing speed). Multivariable random intercept models tested main associations and mediation by depressive symptoms, physical activity, and PM2.5 exposure. Effect modification by race (African Americans/Blacks versus Whites) was tested using interaction terms.

RESULTS

Greater park access (equivalent to 10%more in 1/2-mile around home) was associated with maintained/improved CASI score over six years independent of several covariates including individual- and neighborhood-level socioeconomic status (Odds ratio: 1.04; 95%confidence interval: 1.00-1.08). No other associations were observed with the dichotomous or continuous measures of cognitive change and no mediators were found. While a borderline association was seen between greater park access and maintained/improved CASI for African Americans/Blacks but not for Whites, effect modification was not confirmed by testing interaction terms.

CONCLUSION

Neighborhood park access may help maintain/improve late-life global cognition. However, our findings need replication in other population-based studies and regions. Additionally, studies are needed to determine if associations between park access and change in cognition vary by race/ethnicity to inform intervention efforts.

Neuropsychiatric Symptoms in Mild Cognitive Impairment and Dementia Due to AD: Relation With Disease Stage and Cognitive Deficits

Background: The interaction between neuropsychiatric symptoms, mild cognitive impairment (MCI), and dementia is complex and remains to be elucidated. An additive or multiplicative effect of neuropsychiatric symptoms such as apathy or depression on cognitive decline has been suggested. Unraveling these interactions may allow the development of better prevention and treatment strategies. In the absence of available treatments for neurodegeneration, a timely and adequate identification of neuropsychiatric symptom changes in cognitive decline is highly relevant and can help identify treatment targets. Methods: An existing memory clinic-based research database of 476 individuals with MCI and 978 individuals with dementia due to Alzheimer's disease (AD) was reanalyzed. Neuropsychiatric symptoms were assessed in a prospective fashion using a battery of neuropsychiatric assessment scales: Middelheim Frontality Score, Behavioral Pathology in Alzheimer's Disease Rating Scale (Behave-AD), Cohen-Mansfield Agitation Inventory, Cornell Scale for Depression in Dementia (CSDD), and Geriatric Depression Scale (30 items). We subtyped subjects suffering from dementia as mild, moderate, or severe according to their Mini-Mental State Examination (MMSE) score and compared neuropsychiatric scores across these groups. A group of 126 subjects suffering from AD with a significant cerebrovascular component was examined separately as well. We compared the prevalence, nature, and severity of neuropsychiatric symptoms between subgroups of patients with MCI and dementia due to AD in a cross-sectional analysis. Results: Affective and sleep-related symptoms are common in MCI and remain constant in prevalence and severity across dementia groups. Depressive symptoms as assessed by the CSDD further increase in severe dementia. Most other neuropsychiatric symptoms (such as agitation and activity disturbances) progress in parallel with severity of cognitive decline. There are no significant differences in neuropsychiatric symptoms when comparing "pure" AD to AD with a significant vascular component. Conclusion: Neuropsychiatric symptoms such as frontal lobe symptoms, psychosis, agitation, aggression, and activity disturbances increase as dementia progresses. Affective symptoms such as anxiety and depressive symptoms, however, are more frequent in MCI than mild dementia but otherwise remain stable throughout the cognitive spectrum, except for an increase in CSDD score in severe dementia. There is no difference in neuropsychiatric symptoms when comparing mixed dementia (defined here as AD + significant cerebrovascular disease) to pure AD.

A Survey for Examining the Effects of COVID-19 and Infection Control Measures in Older Persons With Mild Cognitive Impairment and Dementia and Their Caregivers

Background: During the first wave of the COVID-19 pandemic, many non-urgent outpatient services in Italy were closed due to the Government-enforced lockdown period. So far, little is known about what effect the pandemic, quarantine measures, and reductions in medical services had on people with cognitive impairment and their caregivers. Objectives: To develop two versions (i.e., patients and informants/caregivers) of a survey designed to assess the impact of the COVID-19 pandemic during the first Italian lockdown period (11 March -4 May 2020) on Memory Clinic outpatients with Mild Cognitive Impairment (MCI) or dementia, and their caregivers. Design: Psychiatrists, neuropsychologists, and epidemiologists developed two versions: one for patients with Mild Cognitive Impairment and other cognitive disorders, the other for their relatives and/or caregivers. Each version of the survey includes five sections: (a) socio-demographic information and access to technology devices; (b) individual COVID-19 protection methods; (c) knowledge about COVID-19; (d) the effect of COVID-19 on daily life; and (e) the effect of COVID-19 on emotional state. Conclusion: Until an effective vaccine is developed it is likely that future waves of COVID-19 will result in shielding of vulnerable older adults. We believe that this instrument will be useful as a tool to collect information and help clinicians to promptly respond to changes in patients' cognitive, psychiatric, and somatic health needs, and to help for future planning in possible subsequent quarantine periods.

Depression in Alzheimer's Disease: An Alternative Role for Selective Serotonin Reuptake Inhibitors?

Depression is a common co-morbidity seen in people with Alzheimer's disease (AD). However, the successful treatment of depressive symptoms in people with AD is rarely seen. In fact, multiple randomized controlled trials have shown selective serotonin reuptake inhibitors (SSRIs), the current best recommended treatment for depression, to be ineffective in treating depressive symptoms in people with AD. One explanation for this lack of treatment effect may be that depressive symptoms can reflect the progression of AD, rather than clinical depression and are a consequence of more severe neurodegeneration. This raises several questions regarding not only the efficacy of SSRIs in the treatment of depression in people with AD but also regarding the accuracy of diagnosis of depression in AD. However, there may be a rationale for the prescription of SSRIs in early AD. Even in the absence of depression, SSRIs have been shown to slow the conversion from mild cognitive impairment to AD. This may be attributed to the effect of SSRIs on the processing of amyloid-β precursor protein, which may cause a reduction in the accumulation of amyloid-β. Thus, although SSRIs may lack efficacy in treating depression in people with AD, they may hold therapeutic potential for treating and delaying the progression of AD especially if treatment begins in the early stages of AD. This article reviews the current consensus for SSRI treatment of depression in people with AD and highlights the possibility of SSRIs being a treatment option for delaying the progression of AD.

An Exploratory Study of Pathways from White Matter Hyperintensities to Cognitive Impairment through Depressive Symptoms Using Structural Equation Modeling: A Cross Sectional Study in Patients with Dementia

OBJECTIVE

The aim of this study was to model the relationships among white matter hyperintensities (WMHs), depressive symptoms, and cognitive function and to examine the mediating effect of depressive symptoms on the relationship between WMHs and cognitive impairment.

METHODS

We performed structural equation modeling using cross-sectional data from 1158 patients from the Clinical Research for Dementia of South Korea (CREDOS) registry who were diagnosed with mild-to-moderate dementia. Periventricular white matter hyperintensities (PWMHs) and deep white matter hyperintensities (DWMHs) were obtained separately on the protocol of magnetic resonance imaging (MRI). Depression and cognitive function were assessed using the Korean Form of the Geriatric Depression Scale (KGDS) and the Seoul Neuropsychological Screening Battery (SNSB), respectively.

RESULTS

The model that best reflected the relationships among the variables was the model in which DWMHs affected cognitive function directly and indirectly through the depressive symptoms; on the other hand, PWMHs only directly affected cognitive function.

CONCLUSIONS

This study presents the mediation model including the developmental pathway from DWMHs to cognitive impairment through depressive symptoms and suggests that the two types of WMHs may affect cognitive impairment through different pathways.

Internet-Based Cognitive Behavior Therapy Only for the Young? A Secondary Analysis of a Randomized Controlled Trial of Depression Treatment

BACKGROUND

Late-life depression is a major public health concern, driving the development of complementary treatment options. This study investigates the effectiveness and acceptability of internet-based Cognitive Behavioral Therapy (iCBT) in older individuals (60+ years) compared to younger age groups.

MATERIALS AND METHODS

Secondary analysis of a cluster-randomized controlled trial with 647 (18-82 years; mean 43.9) mild to moderately severe depressed primary care patients receiving either iCBT + treatment as usual (TAU) or TAU alone. Severity of depression was measured by the Beck Depression Inventory (BDI-II) at baseline, 6 weeks and 6 months. Intention-to-treat analysis in three age groups (18-39 years, n = 264; 40-59 years, n = 300; 60+ years, n = 83) was performed, using mixed-effects regression models to quantify treatment effect.

RESULTS

No age differences in the effectiveness of iCBT were found. Patients in the intervention group consistently showed a greater reduction in depression severity than controls in all three age groups and at both follow-ups. Effect sizes ranged from d = 0.30 (40-59 years, 6 weeks) to d = 1.91 (60+ years, 6 months). Uptake of the intervention was banded around 70% with no differences between age groups (χ² = 0.18, p = .915). The mean number of completed modules increased with age (χ² = 18.99, p = .040).

DISCUSSION

iCBT is equally effective in both younger and older individuals, thus providing a valuable complementary element of routine late-life depression care.

CLINICAL TRIAL REGISTRATION

DRKS-ID: DRKS00005075 https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00005075.

Depression, Anxiety, and Apathy in Mild Cognitive Impairment: Current Perspectives

Objective: Mild cognitive impairment (MCI) is an important risk state for dementia, particularly Alzheimer's disease (AD). Depression, anxiety, and apathy are commonly observed neuropsychiatric features in MCI, which have been linked to cognitive and functional decline in daily activities, as well as disease progression. Accordingly, the study's objective is to review the prevalence, neuropsychological characteristics, and conversion rates to dementia between MCI patients with and without depression, anxiety, and apathy. Methods: A PubMed search and critical review were performed relating to studies of MCI, depression, anxiety, and apathy. Results: MCI patients have a high prevalence of depression/anxiety/apathy; furthermore, patients with MCI and concomitant depression/anxiety/apathy have more pronounced cognitive deficits and progress more often to dementia than MCI patients without depression/anxiety/apathy. Conclusions and Implications: Depression, anxiety, and apathy are common in MCI and represent possible risk factors for cognitive decline and progression to dementia. Further studies are needed to better understand the role and neurobiology of depression, anxiety, and apathy in MCI.

Effects of COVID-19 Infection Control Measures on Appointment Cancelation in an Italian Outpatient Memory Clinic

Background: In the first wave of the COVID-19 pandemic in 2020, many countries made changes to the routine management of patients with non-communicable diseases, including neurocognitive disorders. Therefore, many "so-called" non-urgent elective procedures and outpatient appointments have been canceled or postponed, possibly impacting negatively on health and well-being of patients in the short- and long-term. Aim: Here, we aimed at describing numbers and types of outpatient appointments canceled as a result of government's restrictive measures in our memory clinic. Methods: The scheduled appointments at the memory clinic of the Santa Lucia Foundation IRCCS, Rome, Italy, are recorded in a comprehensive dataset under strict administrative control. Here, we compared appointments (first-time and follow-up) that were canceled from January to April 2020 with those of the corresponding months in 2019. Results: We observed a substantial decrease in appointments during 2020. The majority of scheduled appointments were follow-up, and about a quarter were first-time appointments. We estimated that 66.7% and 77.4% of patients missed out respectively their first and follow-up appointments in our memory clinic due to government's restrictive measures in March-April 2020. Conclusions: A large number of patients with neurocognitive disorders missed crucial appointments due to government's restrictive measures, and many experienced a delay in initial diagnosis and initiation of treatment. This has relevant impact on their treatment and consequently has (is still having and potentially will have) an increase on the healthcare service burden of clinics. Furthermore, as a second wave of COVID-19 affects Europe, and with winter approaching, it is a compelling priority to ensure easy and rapid access to appropriate assessment, care and treatment in the event of a new outbreak and potential subsequent lockdowns, with particular attention to the development of specific healthcare technologies customized to older persons with cognitive impairment.

Investigation of possible risk factors for depression in Alzheimer's disease: A systematic review of the evidence

BACKGROUND

Depression is common in people with Alzheimer's disease (AD), and is associated with increased risk of institutionalization and mortality. Understanding risk factors for depression in AD is key to its development and treatment.

METHODS

We searched the MEDLINE, EMBASE, PsycINFO, and CINAL databases for longitudinal prospective cohort studies that evaluated risk factors for depression in people with AD. Two authors independently selected articles for inclusion and assessed quality of studies using predetermined criteria.

RESULTS

In seven studies that met the inclusion criteria, 2029 participants were followed up for a median of 5 years. Gender and educational attainment were not predictors of depression risk. History of a past psychiatric disorder and greater cognitive impairment predicted increased risk of depression in more than one study. In single studies, younger age, having a family history of psychiatric disorder, neuroticism, functional decline, presence of sleep disturbance and aggression, and increased cardiovascular risk predicted depression risk. Not being within 6 months of dementia onset and, counterintuitively having two comorbid disorders were protective factors in one study.

LIMITATIONS

A small number of studies exist overall and only a few have examined the same risk factors. Most of the studies have measured depression using scales that are not validated in AD.

CONCLUSIONS

These results inform a preliminary model of depression risk in people with AD. Unlike in the general population, men and women and those with higher and lower educational levels of attainment may be equally at risk of depression. Clinicians should be aware of these possible differences in the risk profile for depression in AD populations, to assist detection and enable early treatment. Interventions to delay cognitive and functional decline may reduce depression risk.

Moderating role of positive aspects of caregiving in the relationship between depression in persons with Alzheimer's disease and caregiver burden

Improving caregivers' positive perception of their role may be important in reducing their subjective burden when caring for Alzheimer's disease (AD) patients with depression. The purpose of present study was to explore the moderating role of the positive aspects of caregiving (PAC) on the subjective burden on family caregivers when managing depressive behaviors. We conducted a cross-sectional study including 200 pairs of patients with mild AD and their caregivers from three communities and two hospitals in Taiyuan, China in October 2014. The latent variable interaction model based on a two stage least squares (2SLS) regression was fitted. A significant moderating effect of the PAC was found on the relationship between depression in patients with AD and the caregiver burden they cause. Caregivers dealing with patients with low levels of depression but with high levels of the PAC had significantly lower levels of caregiver burden compared to those caregivers with the low levels of PAC. Continuously detecting the patient's mental state combined with caregivers having an optimistic attitude towards life may improve the quality of life for both patients and caregivers.

Depression and Dementia in Old-Old Population: History of Depression May Be Associated with Dementia Onset. The Tome Project

Background: In this study, we investigated the relationship among a history of depression, depressive states, and dementia in a community-based old-old cohort.

Methods: From 2012 to 2013, we recruited 200 subjects residing in Tome, Japan. Ultimately, 181 subjects were enrolled in our study and completed the whole study protocol. We used the World Mental Health-Composite International Diagnostic Interview 3.0 to evaluate whether subjects had a history of depression or other affective disorders. Simultaneously, 3.0 Tesla brain magnetic resonance imaging (MRI) was performed for each subject.

Results: Of 181 subjects, 66 were normal (clinical dementia rating [CDR] = 0), 88 had MCI (CDR = 0.5), and 27 had dementia (CDR = 1 or above). Nine of the 181 subjects (4.9%) had a history of depressive episodes. CDR was significantly higher in subjects with a history of depression (0.9 vs. 0.4, p = 0.046) than in those without it. Seventy-two of the 181 subjects (39.7%) exhibited depressive symptoms. Subjects with depression exhibited lower Mini–Mental State Examination scores (21.6 vs. 23.3, p = 0.008), higher CDR scores (0.6 vs. 0.3, p = 0.004), and more atrophy of the medial temporal lobe (4.4 vs. 3.7, p = 0.036).

Conclusion: A history of depression should be considered a risk factor for all-cause dementia. In the old-old population, depression is associated with a higher prevalence of dementia, lower cognitive performance, and a smaller hippocampus.

Prevalence of Dementia, Depression, and Mild Cognitive Impairment in a Rural Area of the Island of Crete, Greece

The studies on the prevalence of dementia, depression, and mild cognitive impairment (MCI) in Greece are sparse and show major variations of prevalence depending on geographical areas, nutritional habits, and the way of living. The aim of this door-to-door study was to find the prevalence of dementia, depression, and MCI in a rural Greek population. Four hundred and forty-three individuals older than 61years following the application of specific criteria were diagnosed with: normal cognition, depression, MCI with and without depression, and dementia with and without depression. Four diagnostic methods were used, 2 of which included Mungas correction for age and education. After Mungas adjustment, the results were as follows-depression: 33.9%; MCI: 15.3%; MCI with depression: 8.6%; dementia: 2.0%; and dementia with depression: 7.2%. Dementia is less prevalent compared to global data and other Greek areas. Mild cognitive impairment is more prevalent than dementia. High percentages of depression may be related to low education.

Supporting Simple Activity Engagement in Persons With Moderate to Severe Alzheimer's Disease Through a Technology-Aided Program

OBJECTIVES

These 2 studies assessed a technology-aided program to support mild physical exercise or simple occupational activity in participants with moderate to severe Alzheimer's disease.

METHODS

Study 1 included 11 participants who were to perform a leg-raising response. Study 2 included 10 participants who were to sort objects into different containers. The program ensured that they received positive stimulation contingent on the responses and reminders/prompts after periods of nonresponding. Each study was carried out according to a nonconcurrent multiple baseline design across participants.

RESULTS

The program was successful in supporting mild physical exercise and activity with objects in the 2 groups of participants, respectively. The participants also showed signs of positive involvement (eg, smiles and verbalizations) during the sessions. Moreover, staff personnel rated the program and its impact positively.

CONCLUSION

The program may be considered a practical resource for supporting positive engagement in persons with moderate to severe Alzheimer's disease.

Differences in Depressive Patterns According to Disease Severityin Early-Onset Alzheimer's Disease

BACKGROUND & OBJECTIVE

Depression frequently combines with dementia, including early-onset Alzheimer's disease (EOAD). We investigated differences in prevalence and characteristics of depressive symptoms according to dementia severity in EOAD patients.

METHODS

The 15-item Korean version of the Geriatric Depression Scale (GDS-15) was administered to 412 EOAD patients. Factor analysis was used to assess GDS-15 factor structure. We subdivided participants into three groups by disease severity, then compared the frequencies and scores of individual GDS-15 items and performed logistic regression analysis to assess associations between depressive symptoms and EOAD stage.

RESULTS

Factor analysis yielded three factor categories: 1) "hopelessness and ominousness" (symptoms no. 6, 8, 12, 14, 15); 2) "unhappiness and dissatisfaction" (no. 1, 3, 5, 7, 11); and 3) "monotony and lack of energy" (no. 2, 4, 9, 10, 13). Factor 2 depressive symptoms (no. 1, 5, 11) were less common in moderate EOAD. The risk of Factor 1 symptoms: no. 12 (OR, 2.04; 95% CI, 1.19-3.50; p = 0.010) and 14 (OR, 1.84; 95% CI, 1.07-3.16; p = 0.028) was higher in mild than very mild EOAD. The risk of Factor 2 symptoms: no. 9 (OR, 2.69; 95% CI, 1.08-6.71; p = 0.033) and 13 (OR, 2.12; 95% CI, 1.02-4.40; p = 0.043) was higher in moderate than mild EOAD.

CONCLUSION

We confirmed that depressive symptoms differ according to EOAD severity. When assessing depressive symptoms related to dementia progression, we recommend focusing on "hopelessness and ominousness" in very mild EOAD and "unhappiness and dissatisfaction" in mild EOAD.

Persons With Advanced Alzheimer’s Disease Engage in Mild Leg Exercise Supported by Technology-Aided Stimulation and Prompts

This study assessed whether nine persons with advanced Alzheimer’s disease would learn to engage in leg responses (exercise) with the support of a technology-aided program, which provided (a) preferred stimulation contingent on the leg responses and (b) verbal reminders/prompts in case of no responding. The study was conducted according to a non-concurrent multiple baseline design across participants and involved sessions of 5 min. During the baseline, the participants’ mean frequencies of leg responses ranged from zero to slightly above two per session. During the intervention, those frequencies ranged from nearly 10 to nearly 17 per session. The mean frequencies of prompts varied across participants from about two to more than seven per session. In addition to the increase in leg responses, participants showed an increase in signs of positive personal involvement (e.g., smiles and positive verbalizations) during the intervention sessions as compared with the baseline sessions. The applicability and potential benefits of the program in daily contexts are discussed.

Unified theory of Alzheimer's disease (UTAD): implications for prevention and curative therapy

The aim of this review is to propose a Unified Theory of Alzheimer's disease (UTAD) that integrates all key behavioural, genetic and environmental risk factors in a causal chain of etiological and pathogenetic events. It is based on three concepts that emanate from human's evolutionary history: (1) The grandmother-hypothesis (GMH), which explains human longevity due to an evolutionary advantage in reproduction by trans-generational transfer of acquired knowledge. Consequently it is argued that mental health at old-age must be the default pathway of humans' genetic program and not development of AD. (2) Therefore, mechanism like neuronal rejuvenation (NRJ) and adult hippocampal neurogenesis (AHN) that still function efficiently even at old age provide the required lifelong ability to memorize personal experiences important for survival. Cumulative evidence from a multitude of experimental and epidemiological studies indicate that behavioural and environmental risk factors, which impair productive AHN, result in reduced episodic memory performance and in reduced psychological resilience. This leads to avoidance of novelty, dysregulation of the hypothalamic-pituitary-adrenal (HPA)-axis and cortisol hypersecretion, which drives key pathogenic mechanisms of AD like the accumulation and oligomerization of synaptotoxic amyloid beta, chronic neuroinflammation and neuronal insulin resistance. (3) By applying to AHN the law of the minimum (LOM), which defines the basic requirements of biological growth processes, the UTAD explains why and how different lifestyle deficiencies initiate the AD process by impairing AHN and causing dysregulation of the HPA-axis, and how environmental and genetic risk factors such as toxins or ApoE4, respectively, turn into disease accelerators under these unnatural conditions. Consequently, the UTAD provides a rational strategy for the prevention of mental decline and a system-biological approach for the causal treatment of AD, which might even be curative if the systemic intervention is initiated early enough in the disease process. Hence an individualized system-biological treatment of patients with early AD is proposed as a test for the validity of UTAD and outlined in this review.

Extrapyramidal Signs and Cognitive Subdomains in Alzheimer Disease

OBJECTIVE

Extrapyramidal signs (EPS), commonly observed in Alzheimer disease (AD), predict cognitive impairment and functional decline. This study investigated the association between EPS and five cognitive subdomains in a large number of participants with AD.

DESIGN

Cross-sectional analyses of the nationwide Clinical Research of Dementia of South Korea (CREDOS) study, 2005-2012.

SETTING

Multicenter clinical settings.

PARTICIPANTS

1,737 participants with AD drawn from the CREDOS study.

MEASUREMENTS

The EPS group was defined by the presence of at least one EPS based on neurologic examination. We assessed five cognitive subdomains: attention, language, visuospatial function, memory, and frontal/executive function using the Seoul Neuropsychological Screening Battery-Dementia version. The associations of EPS with each cognitive subdomain were analyzed with a multiple linear regression model after controlling for confounding factors: sex, age, years of education, severity of dementia (Clinical Dementia Rating Sum of Boxes), and white matter hyperintensities.

RESULTS

164 AD participants (9.4%) had EPS. AD participants with EPS showed lower performance compared with those without EPS in two cognitive subdomains: attention and visuospatial function. The language, memory, and frontal/executive subdomains did not differ between the EPS-positive and the EPS-negative groups. In addition, we found a significant moderating relationship between EPS and deep white matter hyperintensities on visuospatial function score.

CONCLUSIONS

EPS in AD are associated with severe cognitive impairment in attention and visuospatial function. Careful screening for EPS in patients with AD may assist in prediction of cognitive profile.

Technology-Aided Programs to Support Positive Verbal and Physical Engagement in Persons with Moderate or Severe Alzheimer's Disease

Pilot studies using technology-aided programs to promote verbal reminiscence and mild physical activity (i.e., positive forms of engagement) in persons with moderate or severe Alzheimer's disease have provided promising results (Lancioni et al., 2015a,b). The present two studies were aimed at upgrading and/or extending the assessment of those programs. Specifically, Study 1 upgraded the program for verbal reminiscence and assessed it with eight new participants. The upgraded version automatically monitored the participants' verbal behavior during the sessions, in which photos and brief videos were used to foster verbal reminiscence. Monitoring allowed computer approval and reminders to be consistent with the participants' behavior. Study 2 extended the assessment of the program for promoting mild physical activity with 10 new participants for whom arm-raising responses were targeted. The results of Study 1 showed that the participants' mean percentages of intervals with verbal engagement/reminiscence were below 10 during baseline and control sessions and between above 50 and nearly 80 during the intervention. The results of Study 2 showed that the mean frequencies of arm-raising responses were about or below four and between about 10 and 19 per session during the baseline and the intervention, respectively. The general implications of the aforementioned results and the need for new research in the area were discussed.

The Relationship between Serum Endocan Levels and Depression in Alzheimer's Disease

Objectives. Growing evidence suggests that angiogenic vascular factors may be involved in the pathogenic mechanism of Alzheimer's disease (AD), and recently endocan has been proposed as an angiogenic biomarker. The aim of this study was to measure serum endocan levels according to the presence of depression in AD and to investigate the association among the serum endocan levels, cognitive function, and depression in these patients. Methods. Serum endocan levels were measured in 26 AD patients with depression, 29 AD patients without depression, and 29 healthy controls using an enzyme-linked immunosorbent assay kit. The Mini-Mental State Examination-Korean version (MMSE-KC) and the Korean version of the Geriatric Depression Scale-Short Form (SGDS-K) were used to evaluate cognitive function and depressive symptoms, respectively. Results. Serum endocan levels were significantly lower in AD patients with depression than in AD patients without depression or healthy controls. Serum endocan levels were negatively correlated with SGDS-K scores but not with MMSE-KC scores in AD patients. Conclusions. This study suggests that serum endocan levels might be associated with depression in AD. Future studies are needed to investigate the pathophysiological mechanisms or the role of endocan in AD with depression.

Slowing the progression of Alzheimer's disease; what works?

Alzheimer's disease (AD) is an age-related progressive dementia, which is increasing in prevalence world-wide. Typically affecting short-term memory at onset, this devastating illness advances to impair all aspects of cognition, as well as non-cognitive domains. Although much effort has been made in recent years to develop disease-modifying treatments, medications which provided promising results in pre-clinical research have so far faltered in human clinical trials. Attention has recently shifted into trying to identify preventative measures that may delay the onset of the illness. Preventative factors include physical activity, proper diet, cognitive stimulation and the management of conditions such as hypertension, diabetes and obesity. However, it remains imperative to identify approaches that may help patients already diagnosed with the illness. Alongside pharmacological research, much work has been done on uncovering strategies which may slow down the progression of AD. This review aims to summarize evidence supporting or refuting methods impacting on the progression of the disease. AD remains a chronic and serious condition, therefore any intervention delaying the onset of moderate/severe symptoms will have a significant impact on patients and their families.

Patients with moderate Alzheimer's disease engage in verbal reminiscence with the support of a computer-aided program: a pilot study

This study focused on the assessment of a program recently developed for helping patients with moderate Alzheimer’s disease engage in computer-mediated verbal reminiscence (Lancioni et al., 2014a). Sixteen participants were involved in the study. Six of them used the original program version with the computer showing a virtual partner posing questions and providing attention and guidance. The other 10 used a slightly modified program version with the computer presenting photos and videos and providing encouragements to talk as well as attention and guidance. Participants were exposed to brief program sessions individually. The results showed that 15 participants (five of those using the first version and all of those using the second version) had a clear and lasting increase in verbal engagement/reminiscence during the intervention sessions with the program. Those 15 participants had mean percentages of intervals with verbal engagement/reminiscence below 10 during baseline and between about 45 and 75 during the intervention. The results’ implications and the need for new research were discussed.

Persons with Alzheimer's disease engage in leisure and mild physical activity with the support of technology-aided programs

Three studies were conducted to assess technology-aided programs to promote leisure engagement and mild physical activity in persons with Alzheimer's disease. Specifically, Study I assessed a program aimed at enabling three patients with mild or moderate Alzheimer's disease to choose among different music options and activate the preferred ones. Studies II and III were directed at patients in the low moderate or severe stages of the Alzheimer's disease who were no longer capable of ambulating and spent their time generally inactive, sitting in their wheelchairs. In particular, Study II used a program to help three patients exercise an arm-raising movement. Study III used a program to help three patients exercise a leg-foot movement. Each study was carried out according to a nonconcurrent multiple baseline design across patients. Results were very encouraging. The patients of Study I learned to choose and activate their preferred music pieces. The patients of Studies II and III enhanced their performance of the target movements and increased their indices of positive participation (e.g., smiles and verbalizations) during the sessions. The applicability of the programs in daily contexts and their implications for the patients involved are discussed.

Is Dysregulation of the HPA-Axis a Core Pathophysiology Mediating Co-Morbid Depression in Neurodegenerative Diseases?

There is increasing evidence of prodromal manifestation of neuropsychiatric symptoms in a variety of neurodegenerative diseases such as Parkinson's disease (PD) and Huntington's disease (HD). These affective symptoms may be observed many years before the core diagnostic symptoms of the neurological condition. It is becoming more apparent that depression is a significant modifying factor of the trajectory of disease progression and even treatment outcomes. It is therefore crucial that we understand the potential pathophysiologies related to the primary condition, which could contribute to the development of depression. The hypothalamic-pituitary-adrenal (HPA)-axis is a key neuroendocrine signaling system involved in physiological homeostasis and stress response. Disturbances of this system lead to severe hormonal imbalances, and the majority of such patients also present with behavioral deficits and/or mood disorders. Dysregulation of the HPA-axis is also strongly implicated in the pathology of major depressive disorder. Consistent with this, antidepressant drugs, such as the selective serotonin reuptake inhibitors have been shown to alter HPA-axis activity. In this review, we will summarize the current state of knowledge regarding HPA-axis pathology in Alzheimer's, PD and HD, differentiating between prodromal and later stages of disease progression when evidence is available. Both clinical and preclinical evidence will be examined, but we highlight animal model studies as being particularly useful for uncovering novel mechanisms of pathology related to co-morbid mood disorders. Finally, we purpose utilizing the preclinical evidence to better inform prospective, intervention studies.

A computer-aided program for helping patients with moderate Alzheimer's disease engage in verbal reminiscence

This study assessed a simple computer-aided program for helping patients with moderate Alzheimer's disease engage in verbal reminiscence. In practice, the program was aimed at fostering the patient's verbal engagement on a number of life experiences/topics previously selected for him or her and introduced in the sessions through a friendly female, who appeared on the computer screen. The female asked the patient about the aforementioned experiences/topics, and provided him or her with positive attention, and possibly verbal guidance (i.e., prompts/encouragements). Eight patients were involved in the study, which was carried out according to non-concurrent multiple baseline designs across participants. Seven of them showed clear improvement during the intervention phase (i.e., with the program). Their mean percentages of intervals with verbal engagement/reminiscence ranged from close to zero to about 15 during the baseline and from above 50 to above 75 during the intervention. The results were discussed in relation to previous literature on reminiscence therapy, with specific emphasis on the need for (a) replication studies and (b) the development of new versions of the technology-aided program to improve its impact and reach a wider number of patients.

Persons with moderate Alzheimer's disease use simple technology aids to manage daily activities and leisure occupation

Two studies assessed technology-aided programs to support performance of daily activities and selection/activation of music items with patients with moderate Alzheimer's disease. In Study I, four patients were presented with activity-related pictorial instructions via a computer fitted with inexpensive, commercial software. In Study II, four patients were (a) presented with different music options and (b) allowed to select and activate the preferred option via a microswitch response. Study I showed that each patient learned to perform the two activities available with percentages of correct responses exceeding 85 by the end of the intervention. Study II showed that all patients learned to choose and activate music options. Psychology students, employed in a social validation check, scored the patients' behavior within the program better than their behavior in a control situation. The relevance and usability of simplified pictorial-instruction programs and music choice programs for patients with moderate Alzheimer's disease were discussed.

Impaired cognition in depression and Alzheimer (AD): a gradient from depression to depression in AD

Objective To assess cognition in major depressed (MD), Alzheimer's disease (AD), and depression in AD elderly. Method Subjects were evaluated by Mini Mental, Rey Auditory Verbal Learning Test, Rey Complex Figure, Digit Span, Similarities, Trail Making A/B, Verbal Fluency and Stroop. One-way ANOVA and multivariate models were used to compare the performance of each group on neuropsychological tests. Results We evaluated 212 subjects. Compared to MD, attention, working memory, processing speed and recall showed significantly better in controls. Controls showed significantly higher performance in all cognitive measures, except in attention compared to AD. Verbal fluency, memory, processing speed and abstract reasoning in MD was significantly higher compared to AD. AD was significantly better in general cognitive state than depression in AD. All other cognitive domains were similar. Conclusion A decreasing gradient in cognition appeared from the control to depression in AD, with MD and AD in an intermediate position.

Behavioral and psychological symptoms in Alzheimer's disease

Neuropsychiatric symptoms (NPS) such as depression, apathy, aggression, and psychosis are now recognized as core features of Alzheimer's disease (AD), and there is a general consensus that greater symptom severity is predictive of faster cognitive decline, loss of independence, and even shorter survival. Whether these symptoms result from the same pathogenic processes responsible for cognitive decline or have unique etiologies independent of AD-associated neurodegeneration is unclear. Many structural and metabolic features of the AD brain are associated with individual neuropsychiatric symptoms or symptom clusters. In addition, many genes have been identified and confirmed that are associated with symptom risk in a few cases. However, there are no single genes strongly predictive of individual neuropsychiatric syndromes, while functional and structural brain changes unique to specific symptoms may reflect variability in progression of the same pathological processes. Unfortunately, treatment success for these psychiatric symptoms may be lower when comorbid with AD, underscoring the importance of future research on their pathobiology and treatment. This review summarizes some of the most salient aspects of NPS pathogenesis.

Coupled cognitive and functional change in Alzheimer's disease and the influence of depressive symptoms

In Alzheimer's disease (AD), cognition and function are only moderately correlated in cross-sectional studies, and studies of their longitudinal association are less common. One potential non-cognitive contributor to function is depression, which has been associated with poorer clinical outcomes. The current study investigated longitudinal associations between functional abilities, cognitive status, and depressive symptoms in AD. 517 patients diagnosed with probable AD and enrolled in The Multicenter Study of Predictors of Disease Course in Alzheimer's Disease were included. Patients were followed at 6-month intervals over 5.5 years. Longitudinal changes in the Blessed Dementia Rating Scale, modified Mini-Mental State Exam, and the depression subscale of the Columbia University Scale for Psychopathology in AD were examined in a multivariate latent growth curve model that controlled for gender, age, education, and recruitment site. Results showed that cognition and function worsened over the study period, whereas depressive symptoms were largely stable. Rates of change in cognition and function were correlated across participants and coupled within participants, indicating that they travel together over time. Worse initial cognitive status was associated with faster subsequent functional decline, and vice versa. Higher level of depressive symptoms was associated with worse initial functioning and faster subsequent cognitive and functional decline. These findings highlight the importance of both cognitive and psychiatric assessment for functional prognosis. Targeting both cognitive and depressive symptoms in the clinical treatment of AD may have incremental benefit on functional abilities.