Major depression in a population of demented and nondemented older people: prevalence and correlates

Associations of Depressive Symptoms with Subjective Cognitive Decline in Elderly People-A Cross-Sectional Analysis from the AgeWell.de-Study

To develop effective dementia prevention strategies, it is necessary to understand risk factors, associated factors and early signs of dementia. Subjective cognitive decline (SCD) is the earliest form of dementia. The aim of this study is to assess depression as a factor that is significantly associated with SCD. The data of 1030 general practitioner patients from the AgeWell.de-study (60-77 years; CAIDE dementia risk score ≥ 9) were analysed. A descriptive analysis was conducted using validated instruments like the Geriatric depression scale (GDS), Lubben social network scale (LSNS-6) and education classes according to CASMIN (Comparative Analysis of Social Mobility in Industrial Nations). A multivariate regression model with the dependent variable SCD was calculated. Of the 1030 participants, 5.9% had depressive symptoms and 31.3% SCD. The group with depressive symptoms showed significantly higher body-mass-index (p = 0.005), lower education class (p = 0.022), lower LSNS-6 score (p < 0.001), higher sports activity (p < 0.001), and more sleeping problems (p = 0.026). In the regression model a higher GDS-score [Odds ratio (OR): 1.219 (p < 0.001)], more sleeping problems [OR: 1.550 (p = 0.017)] and higher education class [middle/high: OR: 1.474/1.875 (p = 0.037/0.004)] were significantly associated with SCD. This study identified depressive symptoms, sleeping problems, and higher education classes as factors associated with SCD, which can represent an early form of dementia.

The Interface between Depression and Alzheimer's Disease. A Comprehensive Approach

Depression and Alzheimer's disease (AD) are frequent interacting diseases in the elderly with a negative impact on the quality of life of patients and caregivers. Late-life depression may be regarded either as an early symptom of AD or a risk factor for AD, depending on the context. This review was focused on the latest developments in the fields of the neurobiological basis and treatment of depression in AD. We found that some plausible hypotheses are emerging to correlate with depression in AD, such as neuroinflammation and dysimmune regulation. It seems that depression is not related to amyloid deposition, but this issue is not completely resolved. The response to antidepressants is controversial according to the evidence from 10 small double-blind randomized placebo-controlled clinical trials with antidepressants in AD patients with depression: four with sertraline, one with three arms (sertraline, mirtazapine, placebo), one with fluoxetine, one with imipramine, one with clomipramine, one with escitalopram, and one with vortioxetine. The total number of treated patients completing the trials was 638. The main criterion of a positive response was a reduction in the scores of clinical scales for depression of at least 50%. The weighted OR (odds ratio) was calculated with the method of Mantel-Haenszel: 1.29; 95% CI: 0.77-2.16. No significant differences were found compared with placebo. Antidepressants did not have a meaningful negative influence on cognition, which was measured with the mini-mental state examination (MMSE) in 18 clinical trials. Alternatives other than drugs are also discussed. Although there have been important advances in this field, pathophysiology and treatment deserve further research.

Prevalence of Behavioral and Psychological Symptoms of Dementia in Community-Dwelling Dementia Patients: A Systematic Review

Background: Identifying the characteristics of behavioral and psychological symptoms of dementia (BPSD) associated with different dementia types may be a promising strategy to effectively deal with BPSD. We aimed to synthesize the prevalence rates of BPSD characteristics in community-dwelling dementia patients. Methods: We searched Medline, EMBASE, and PsycARTICLES databases for original clinical studies published until December 2020 that enrolled at least 300 community-dwelling dementia patients. The methodological qualities of prevalence studies were assessed using the Joanna Briggs Institute's critical appraisal checklist. Results: Thirty studies were included. The prevalence of the BPSD characteristic ranged from 4 (elation and mania) to 32% (apathy) in the pooled samples. The prevalence of delusions, anxiety, apathy, irritability, elation and mania, and aberrant motor behavior in Alzheimer's disease patients was 1.72-2.88 times greater than that in vascular dementia (VD) patients, while the prevalence of disinhibition in VD patients was 1.38 times greater. The prevalence of anxiety, irritability, and agitation and aggression, delusion, hallucinations, apathy, disinhibition, and aberrant motor behavior tended to increase as the severity of dementia increased, while that of depression, eating disorder, sleep disorders, and elation and mania tended to stable. In community-dwelling patients with dementia, the pooled prevalence of apathy, depression, anxiety, irritability, agitation and aggression, sleep disorders, and eating disorder was higher than 20%, while that of disinhibition and elation and mania was lower than 10%. Conclusion: Overall, the pooled prevalence of apathy, depression, anxiety, irritability, agitation and aggression, sleep disorders, and eating disorder was generally high in patients with dementia. Also, the prevalence of some BPSD characteristics differed according to the type and the severity of dementia. The methodological quality of the included studies is not the best, and high heterogeneity may affect the certainty of the findings. However, the results of this review can deepen our understanding of the prevalence of BPSD. Systematic Review Registration: https://osf.io/dmj7k, identifier: 10.17605/OSF.IO/DMJ7K.

Prevalence of Depression, Anxiety and PTSD in People with Dementia: a Systematic Review and Meta-Analysis

There appears to be a link between depression/anxiety/PTSD and dementia, although the evidence is incomplete and the reason is unclear. Mental illness may cause dementia or may be prodromal or comorbid with dementia, or dementia may trigger a relapse of symptoms in individuals with a history of mental illness. This study examined the link between depression/anxiety/PTSD and dementia by evaluating the prevalence of these disorders in people with dementia, relative to their healthy peers. Existing meta-analyses have examined the prevalence of clinically-significant depression and anxiety in Alzheimer's disease (AD), and depression in frontotemporal dementia (FTD), but have not considered vascular dementia (VaD), dementia with Lewy bodies (DLB), PTSD, or anxiety in FTD. The current meta-analysis compared the prevalence of clinically-significant depression, anxiety and PTSD in the four most common types of dementia (AD, VaD, DLB, FTD) and in unspecified dementia to that of healthy controls (PROSPERO number: CRD42017082086). PubMed, EMBASE, PsycINFO and CINAHL database searches identified 120 eligible studies. Prevalence rates were calculated for depression and anxiety in AD, VaD, DLB, FTD, unspecified dementia, and controls. PTSD data were only available for unspecified dementia. Subgroup analyses indicated that depression, but not anxiety, was more prevalent in people with dementia compared to controls; however, the anxiety analyses were probably under-powered. The results support a link between depression and dementia; however, the link between anxiety or PTSD and dementia remains unclear due to insufficient data. Longitudinal data is now needed to clarify whether depression/anxiety/PTSD may be risk factors for dementia.

Physical and mental health status and their correlations among older wheelchair users with dementia in long-term care facilities

PURPOSE

To investigate the physical health (daily functioning and functional fitness) and mental health (depression and behavioral dysfunction) of older wheelchair users with dementia in long-term care facilities, examine the correlations between physical and mental health, and identify the independent variables of their daily functioning.

METHODS

A descriptive correlational method was adopted, which was conducted in six long-term care facilities in three cities, south Taiwan. Participants comprised 98 older wheelchair users with dementia. Data were collected using structured questionnaires (Mini-Mental State Examination, Barthel Index, Cornell Scale for Depression in Dementia, and Clifton Assessment Procedures for the Elderly Behavior Rating Scale) and from functional fitness testing (cardiopulmonary functioning, body flexibility, joint mobility, and muscle strength and endurance).

RESULTS

Older adults with dementia who had high depression scores were likely to have more behavioral dysfunctions, poorer performance in shoulder flexion and abduction, and lower upper limb muscle strength and endurance. More behavioral dysfunctions were associated with poorer daily functioning, lung capacity, body flexibility, shoulder flexion, and upper limb muscle strength and endurance. Those with better lung capacity, body flexibility, upper limb muscle strength, and endurance were likely to have high daily functioning scores (all p < .05). The key independent variables associated with daily functioning were behavioral dysfunction, lower body flexibility, and lung capacity, which together explained 59.3% of the total variance.

CONCLUSIONS

Further research should develop appropriate activity-based intervention programs for older wheelchair users with dementia to delay their deterioration and promote their physical and mental health.

The relationship among unawareness of memory impairment, depression, and dementia in older adults with memory impairment in Singapore

BACKGROUND

Previous research has studied the relationships among unawareness of memory impairment, depression, and dementia in older adults with severe dementia, but it has not considered the associations and clinical implications at earlier stages of memory impairment. This study therefore sought to examine the relationship among unawareness of memory impairment, depression, and dementia in older adults with memory impairment in Singapore.

METHODS

The participants were 751 older adults with memory impairment in Singapore. They were assessed for objective and subjective memory loss, depression, and dementia severity. Participants' subjective memory loss was determined based on a self-appraisal question on memory, and their objective memory loss was calculated based on their performance on three cognitive tasks. Unawareness was assessed based on the contrast between subjective and objective memory loss.

RESULTS

Descriptive statistics revealed a high prevalence of unawareness (80.4%). Logistic regression analysis revealed that gender and marital status were significantly associated with unawareness. Men (odds ratio (OR) = 2.5) and those who were divorced or separated (OR = 23.0) were more likely to be unaware than women and those who were married, respectively. After chronic conditions and demographic characteristics were controlled for, multivariate logistic regression analyses revealed that older adults with depression were less likely (OR = 0.2) to be unaware than those without depression. Unawareness was also related with dementia severity; older adults with questionable (OR = 0.3) and mild dementia (OR = 0.4) were less likely to be unaware than someone without dementia.

CONCLUSION

Unawareness of memory impairment was common among older adults with memory impairment. However, unawareness may be the result of denial as a strategy for coping with memory loss of which the older adult is aware. Psychological care should be integrated into the overall treatment management of dementia to mitigate the possible risk of depression while increasing individual awareness of memory loss.

Prevalence of depression: Comparisons of different depression definitions in population-based samples of older adults

BACKGROUND

Depression prevalence in older adults varies largely across studies, which probably reflects methodological rather than true differences. This study aims to explore whether and to what extent the prevalence of depression varies when using different diagnostic criteria and rating scales, and various samples of older adults.

METHODS

A population-based sample of 3353 individuals aged 60-104 years from the Swedish National Study on Aging and Care in Kungsholmen (SNAC-K) were examined in 2001-2004. Point prevalence of depression was estimated by: 1) diagnostic criteria, ICD-10 and DSM-IV-TR/DSM-5; 2) rating scales, MADRS and GDS-15; and 3) self-report. Depression prevalence in sub-samples by dementia status, living place, and socio-demographics were compared.

RESULTS

The prevalence of any depression (including all severity grades) was 4.2% (moderate/severe: 1.6%) for ICD-10 and 9.3% (major: 2.1%) for DSM-IV-TR; 10.6% for MADRS and 9.2% for GDS-15; and 9.1% for self-report. Depression prevalence was lower in the dementia-free sample as compared to the total population. Furthermore, having poor physical function, or not having a partner were independently associated with higher depression prevalence, across most of the depression definitions.

LIMITATIONS

The response rate was 73.3% and this may have resulted in an underestimation of depression.

CONCLUSION

Depression prevalence was similar across all depression definitions except for ICD-10, showing much lower figures. However, independent of the definition used, depression prevalence varies greatly by dementia status, physical functioning, and marital status. These findings may be useful for clinicians when assessing depression in older adults and for researchers when exploring and comparing depression prevalence across studies.

Symptoms of Apathy Independently Predict Incident Frailty and Disability in Community-Dwelling Older Adults

OBJECTIVE

Although depressive symptoms are widely recognized as a predictor of functional decline among older adults, little is known about the predictive utility of apathy in this population. We prospectively examined apathy symptoms as predictors of incident slow gait, frailty, and disability among non-demented, community-dwelling older adults.

METHODS

We examined 2 independent prospective cohort studies-the LonGenity study (N = 625, 53% women, mean age = 75.2 years) and the Central Control of Mobility in Aging (CCMA) study (N = 312, 57% women, mean age = 76.4 years). Individuals were recruited from 2008 to 2014. Apathy was assessed using 3 items from the Geriatric Depression Scale. Slow gait was defined as 1 standard deviation or more below age- and sex-adjusted mean values, frailty was defined using the Cardiovascular Health Study criteria, and disability was assessed with a well-validated disability scale.

RESULTS

The prevalence of apathy was 20% in the LonGenity cohort and 26% in the CCMA cohort. The presence of apathy at baseline, independent of depressive symptoms (besides apathy), increased the risk of developing incident slow gait (hazard ratio [HR] = 2.10; 95% CI, 1.36-3.24; P = .001), frailty (HR = 2.86; 95% CI, 1.96-4.16; P < .001), and disability (HR = 3.43; 95% CI, 1.73-6.79; P < .001) in the pooled sample. These associations remained significant when accounting for demographics, medical illnesses, and cognitive function.

CONCLUSIONS

Apathy is associated with increased risk of developing slow gait, frailty, and disability, independent of other established risk factors, in non-demented older adults. Apathy should be screened for as a potentially preventable cause of functional decline in clinical psychiatric settings.

[Depression: A predictor of dementia]

Many studies suggest that in 10-25% of cases of Alzheimer's, the most common dementia in our society, can be prevented with the elimination of some risk factors. Barnes and Yaffe found that one-third of Alzheimer's cases are attributable to depression, but in the scientific literature it is not clear if it has a real causal effect on the development of dementia. The purpose of this study is to analyse the scientific evidence on the hypothesis that depression increases the risk of developing dementia. A systematic review and a meta-analysis were performed on the scientific literature published up until the present day, searching articles that were published between 1990 and 2014. Ten of the studies found met the selection criteria -similar to a) size and characteristics of the sample (origin, age…), b) process of gathering data c) method of studying the relationship (within and/or between group comparison), and d) statistical analysis of the results- and the previously established quality. The value of odds ratio varied from 1.72 to 3.59, and the hazard ratio from 1,72 to 5.44. This indicates that the subjects with a history of depression have a higher risk of developing dementia than others who did not suffer depression.

Learning from Normal Aging: Preserved Emotional Functioning Facilitates Adaptation among Early Alzheimer's Disease Patients

Alzheimer's disease (AD) has been largely characterized by severe deterioration of cognitive functioning. Only recently has more attention been shifted to identifying the preserved capacity and functioning of AD patients. By reviewing the AD literature, we observe that despite the various cognitive impairment and deficits, early Alzheimer's patients perform certain types of automatic emotion regulation and display a positivity effect in emotion recognition and emotional memory. Moreover, we argue that, like their healthy aged peers, the optimization of such preserved emotion-based capacities helps early AD patients increase positive emotions, which may counteract the negative effects of the disease, thus maintaining their socio-emotional functioning. Finally, we discuss the emotion-based capacities strategies that AD patients may use to facilitate their adjustment to a life with Alzheimer's.

The independent contributions of cognitive impairment and neuropsychiatric symptoms to everyday function in older adults

The everyday functional capacities of older adults are determined by multiple factors. The primary goal of the present study was to evaluate whether apathy and depression have unique influences on degree of functional impairment, independent of the effects of specific cognitive impairments. Participants included 344 older adults (199 normal, 87 with MCI, 58 with dementia). The Everyday Cognition (ECog) scales were used to measure both global and domain-specific functional abilities. Neuropsychiatric symptoms of depression and apathy were measured by the Neuropsychiatric Inventory (NPI), and specific neuropsychological domains measured included episodic memory and executive functioning. Results indicated that worse memory and executive function, as well as greater depression and apathy, were all independent and additive determinants of poorer functional abilities. Apathy had a slightly more restricted effect than the other variables across the specific functional domains assessed. Secondary analysis suggested that neuropsychiatric symptoms may be more strongly associated with everyday function within cognitively normal and MCI groups, while cognitive impairment is more strongly associated with everyday function in dementia. Thus, a somewhat different set of factors may be associated with functional status across various clinical groups.

Prevalence and characteristics of mild cognitive impairment in the general population. Data from an Italian population-based study: The Faenza Project

The aim of this cross-sectional study is to investigate mild cognitive impairment (MCI) using the Mini-Mental State Examination in an Italian cohort (N = 6921; mean age 71.6 ± 7.5; 59.2% women). First, we applied psychometrically derived criteria for MCI regardless of presence/absence of subjective cognitive complaints (SCC); second, we implemented the analyses only on the SCC subsample. The estimated MCI prevalence was 6.0%. Amnestic- and non-amnestic MCI single domains accounted for 4.3% and 13.5% of the cases, respectively. Amnestic- and non-amnestic MCI multiple domains occurred in 2.0% and 4.5% of the cases, respectively. The 33.8% of the SCC subsample (6.0% of the cohort) had MCI. Stroke, diabetes and depressive symptoms were commonly associated to MCI suggesting that this common condition is associated with many correlates in Italian older persons. It deserves attention since it is early detectable and potentially preventable.

Depressive symptoms as predictor of dementia versus continuous cognitive decline: a 3-year prospective study

Previous research including meta-analytic efforts supports the assumption that depression is able to predict dementia. The mechanisms of this association still remain to be revealed. Some possible explanations as, for example, the glucocorticoid cascade hypothesis assumes that there are underlying changes at the cortical level that drive the association. Therefore, gradual levels of depressive symptoms may also predict gradual change (decline) in cognitive performance. However, testing both of these predictions (depressive symptoms lead to dementia, and depressive symptoms lead to cognitive decline, respectively) with the same data has to our knowledge not been done in the previous literature. A sample of 562 participants aged 65 or older was examined four times over a period of 3 years. Study participants completed established measures of depression and cognitive functioning. Results based on Cox regression analysis showed that depressive symptoms were not able to predict the conversion to dementia during the following 3 years. Additionally, structural equation models as well as latent change score models did not support the assumption that depressive symptoms predict cognitive decline, measured as a continuous variable. We discuss several possibilities to explain these findings including the potential and possible limits of the glucocorticoid cascade hypothesis.

History of depression prior to Alzheimer's disease and vascular dementia verified post-mortem

The aim of this study was to analyze the medical history, with regards to previous remote depression, in patients with neuropathologically verified Alzheimer's disease (AD), vascular dementia (VaD) and mixed AD/VaD. The 201 patients included (115 AD, 44 VaD and 42 mixed AD/VaD) had been referred to the Psychogeriatric/Psychiatric Department, Lund University Hospital, for psychogeriatric investigation and were followed-up with clinical records and detailed information on psychiatric history prior to the onset of dementia. Depression was considered to exist when the patient had consulted a psychiatrist or physician and had been diagnosed with a "depressive episode" or "depression" and when anti-depressants and/or other specific treatments had been prescribed. Twenty patients (10%) had suffered from depression earlier in life well before the onset of dementia. Eight of the 9 AD patients with a previous diagnosis of depression had suffered from only one depressive episode and all had responded well to treatment, with complete recovery. In the VaD group, 8 out of 9 patients suffered two or more depressive episodes and only two recovered completely. Events with a possible significant relationship to depression were seen in 8 of the 9 AD patients but in only 1 of the 9 VaD patients. Psychotic symptoms were more common in VaD than in the AD group. The treatment modality of depression was similar in the groups. In conclusion, a history of depression prior to dementia is more common and more therapy-resistant in VaD than in AD.

Behavioral disturbance in dementia

Behavioral disturbances are frequently the most challenging manifestations of dementia and are exhibited in almost all people with dementia. Common behavioral disturbances can be grouped into four categories: mood disorders (e.g., depression, apathy, euphoria); sleep disorders (insomnia, hypersomnia, night-day reversal); psychotic symptoms (delusions and hallucinations); and agitation (e.g., pacing, wandering, sexual disinhibition, aggression). They are often persistent, greatly diminish quality of life of patients and their family caregivers, cause premature institutionalization, and pose a high economic burden on the patient, family, and society. Behavioral disturbances can be prevented and treated with a multifaceted approach that supports dignity and promotes comfort and quality of life of persons with dementia and their family members. Management involves prompt treatment of reversible factors and management of symptoms using primarily individualized nonpharmacological interventions. Pharmacological interventions need to be restricted to behavioral emergencies and for short-term treatment of behavioral disturbances that pose imminent danger to self or others.

Depressive symptoms predict decline in perceptual speed in older adulthood

Depressive symptoms and cognitive decline are associated in older age, but research is inconsistent about whether one condition influences the development of the other. We examined the directionality of relations between depressive symptoms and perceptual speed using bivariate dual change score models. Assessments of depressive symptoms and perceptual speed were completed by 1,206 nondemented older adults at baseline, and after 2, 8, 11, and 15 years. After controlling for age, education, baseline general cognitive ability, and self-reported health, allowing depressive symptoms to predict subsequent change in perceptual speed provided the best fit. More depressive symptoms predicted subsequently stronger declines in perceptual speed over time lags of 1 year.

Evaluating the Cornell Scale for Depression in Dementia as a proxy measure in nursing home residents with and without dementia

OBJECTIVES

We evaluated the use of the Cornell Scale for Depression in Dementia (CSDD) as a proxy measure. Study questions were: How do residents' self-reports on the CSDD compare with the nurse proxy CSDD ratings of the resident? How do characteristics of depression as rated by the resident CSDD and the nurse CSDD compare? To what extent are demographic and clinical variables associated with resident CSDD, nurse CSDD, and the discrepancy between resident and nurse CSDD scores?

METHODS

Residents and nurse proxy pairs (n=395 pairs) from 28 nursing homes (NHs) participated. We calculated discrepancy scores for total and subscale CSDD scores, examined correlations between resident and nurse CSDD scores, and described rates of clinical depression using each of the scores. We conducted multivariate analyses to examine factors associated with resident and nurse CSDD and discrepancy scores.

RESULTS

On average, participants had mild cognitive impairment, were White, and female. Associations between resident and nurse CSDD were low (r=0.16). The mean discrepancy score was -2.03 (SD=5.28, p<0.001), indicating that nurses evaluated residents as less depressed than residents evaluated themselves. Discrepancy scores were not associated with residents' cognitive status, but were associated with a measure of self-report reliability. Regression analyses indicated that depression diagnosis accounted for a small but significant association with resident CSDD, but was not significantly associated with nurse CSDD.

CONCLUSION

These findings underscore the importance of obtaining resident input when assessing depression in NH residents with dementia, and educating NH nurses in the most effective ways to assess depression.

The complex relationship between depression and dementia

Dementia and depression are mental health problems that are commonly encountered in neuropsychiatric practice in the elderly. Approximately, half of the patients with late-onset depression have cognitive impairment. The prevalence of depression in dementias has been reported to be between 9 and 68%. Depression has been both proposed to be a risk factor for dementia as well as a prodrome of dementia. This article is a selective literature review of the complex relationship between the two conditions covering definitions, epidemiology, related concepts, treatment, and emerging biomarkers. The methodological issues and the mechanisms underlying the relationship are also highlighted. The relationship between the two disorders is far from conclusive.

Depression among the very old with dementia

OBJECTIVES

The aim of this study was to investigate the prevalence of depression among very old individuals with dementia compared to those without dementia and to examine if there were any differences regarding associated factors between people with or without depression in these conditions.

METHODS

In a population-based study in Sweden, 363 participants aged 85 years and above, were evaluated for depression and dementia.

RESULTS

The prevalence of depression was significantly higher among the people with dementia than without dementia, 43% vs. 24% (p < 0.001). Approximately 2/3 of the depressed in both groups used antidepressants and of those, approximately 50% had responded. Depression in the group without dementia was, among other factors, associated with higher total number of medication, the use of significant more analgesics and benzodiazepines, loneliness, inability of going outside and recent loss of child. The loss of a child was the only factor that was independently associated with depression in those with dementia.

CONCLUSIONS

The present study confirms that in the very old, depression is more common among people with dementia than without dementia. A large proportion, both with and without dementia, are under-diagnosed and untreated, and in addition many subjects in both groups studied were non-responders to treatment. Many of the factors associated with depression among people without dementia in this study were not associated with depression among those with dementia, thus supporting the theory that the spectrum of associated factors for depression in dementia seems to be different from that for depression in people without dementia.

One-week prevalence of depressive symptoms and psychotropic drug treatments among old people with different levels of cognitive impairment living in institutional care: changes between 1982 and 2000

BACKGROUND

Dementia and depression are common in advanced age, and often co-exist. There are indications of a decreased prevalence of depressive symptoms among old people in recent years, supposedly because of the manifold increase in antidepressant treatment. Whether the prevalence of depressive symptoms has decreased among people in different stages of dementia disorders has not yet been investigated.

METHODS

A comparison was undertaken of two cross-sectional studies, conducted in 1982 and 2000, comprising 6864 participants living in geriatric care units in the county of Västerbotten, Sweden. Depressive symptoms were measured using the Multi-Dimensional Dementia Assessment Scale (MDDAS), and the cognitive score was measured with Gottfries' cognitive scale. Drug data were obtained from prescription records.

RESULTS

There was a significant decrease in depressive symptom score between 1982 and 2000 in all cognitive function groups except for the group with moderate cognitive impairment. Antidepressant drug use increased in all cognitive function groups.

CONCLUSION

The prevalence of depressive symptoms decreased between 1982 and 2000, in all levels of cognitive impairment except moderate cognitive impairment. This might possibly be explained by the depressive symptoms having different etiologies in different stages of a dementia disorder, which in turn might not be equally susceptible to antidepressant treatment.

Approach to major depression in old people

BACKGROUND

The difficulty in identifying and distinguishing Major Depressive Disorder (MDD) in primary care is well known. The main objective of this study is to determine the frequency of MDD in persons aged 65 years and older using the Detection of Depression in the Elderly Scale (DDES). A second objective is to determine the convergent validity of the DDES with the Geriatric Depression Scale (GDS).

METHODS

A cross-sectional, observational study was carried out of 1,387 subjects aged 65 years and older. The variables considered were: affective state (GDS and DDES), physical and cognitive functional state, health problems and sociodemographic characteristics.

RESULTS

Using the DDES we identified MDD in 50 subjects (4.3%). There was a moderate correlation (r = 0.570; p < 0.001) between the DDES and the GDS scores (p < 0.001). According to logistic regression analysis, the variables associated with a probable MDD (DDES +) were: dependence in activities of daily living (OR: 3.3), female gender (OR: 2.3), marital status single/widowed/divorced (OR: 2.0), and the presence of four of more health problems (OR: 2.1).

CONCLUSIONS

Using the DDES scale we found a 4.3% prevalence of MDD in a representative sample of older adults. Compared to the GDS, the most commonly used scale, the DDES may be considered a more sensitive screening tool for the identification of MDD in primary care.

Depression in Dutch homes for the elderly: under-diagnosis in demented residents?

OBJECTIVE

Although community-based studies reported an increased incidence of depression among demented persons compared with non-demented persons, it is not clear whether this relationship also exists among institutionalised elderly persons. The aim of this study was to compare the prevalence of diagnosed depressive disorders and mood symptoms between demented and non-demented residents living in Dutch homes for the elderly.

METHODS

Cross-sectional analysis in 16 homes for the elderly of routine outcome measurements by trained nurse assistants using the Resident Assessment Instrument (RAI) between January 2007 and April 2008. Nurse assistants recorded all known medical diagnoses including dementia and depression, as well as a structured observation of the presence or absence of 11 mood symptoms over the last 3 days.

RESULTS

313 demented and 463 non-demented residents with complete data were included (99% of all residents, mean age 84 years). 24.6% of participants were diagnosed with a depressive disorder, with no statistically significant difference between demented and non-demented persons (p = 0.237). Mood symptoms were more prevalent in demented residents (p < 0.001, OR 2.14, 95%CI 1.56-2.93). Among residents with mood symptoms, demented residents were less likely to be diagnosed with a depressive disorder than non-demented residents (p = 0.039, OR 0.61, 95%CI 0.38-0.98).

CONCLUSIONS

The prevalence of diagnosed depressive disorders was comparable between demented and non-demented residents. However, demented residents suffered more from mood symptoms and may be at risk of under-diagnosis of depression.

Subtypes of depression among patients with Alzheimer's disease and other dementias

OBJECTIVES

We compared the prevalence of subtypes of depression in patients with Alzheimer's disease (AD), vascular dementia (VaD), and unspecified dementia (UD).

METHODS

Using the Integrated Healthcare Information Services database, we conducted an analysis of subtypes of depression (major depressive disorder, depressive disorder not otherwise specified, dysthymic disorder; depressive psychosis, and adjustment disorder depressive) among patients with AD, VaD, and UD. Six thousand four hundred and forty patients aged 60 years or older with dementia (2947 with AD, 725 with VaD, and 2768 with UD) were identified from January 1 to December 31, 2001. Both subtypes of depression and dementia subgroups were diagnosed using criteria from the International Classification of Diseases, 9th version.

RESULTS

The overall prevalence of depressive disorders was 27.41%. The prevalence of depressive disorders was significantly higher in VaD (44.14%) and UD (32.48%) patients compared with AD (18.53%, P < .0001) patients. The AD patients had the lowest prevalence of all subtypes of depression. The VaD patients, compared with both AD and UD (P < .005), had a significantly higher prevalence of: 1) depressive disorder not otherwise specified, 2) major depressive disorder, and 3) dysthymic disorder. Adjustment disorder with depressive symptoms was more common in the UD subgroup, whereas the rate of depressive psychosis was similar in all dementia subgroups

CONCLUSIONS

This study supports the view that depressive disorders are more prevalent in VaD compared with UD and AD, and provides indicators to the clinician for further evaluation of depression in dementia subgroups.

Trends in mental health admissions to nursing homes, 1999-2005

OBJECTIVE

The study examined 1999-2005 data on first-time nursing home admissions of individuals with mental illness, dementia, or both to identify trends and characteristics.

METHODS

The Minimum Data Set was used to estimate the number and percentage of persons newly admitted to nursing homes who had mental illness (schizophrenia, bipolar disorder, depression, or an anxiety disorder), dementia, or both from 1999 to 2005. Data from 2005 were used to compare demographic characteristics and comorbid conditions of the three groups and treatments received.

RESULTS

The number of individuals admitted with mental illness increased from 168,721 in 1999 to 187,478 in 2005. The 2005 number is more than 50% higher than the number admitted with dementia only (118,290 in 2005). The increase was driven by growth in admissions of persons with depression--from 128,566 to 154,262 in 2005. Persons admitted with depression had higher rates of comorbid conditions than those admitted with dementia or with neither dementia nor mental illness. They also had high rates of antidepressant treatment and high rates of receipt of training in skills required to return to the community.

CONCLUSIONS

Current trends show that the proportion of nursing home admissions with mental illness, in particular depression, has overtaken the proportion with dementia. These changes may be related to increased recognition of depression, availability of alternatives to nursing homes for persons with dementia, and increased specialization among nursing homes in the care of postacute, rehabilitation residents. In light of these trends, it is critical to ensure that nursing homes have resources to adequately treat residents with mental illness to facilitate community reintegration.

A population-based study of the association between Trypanosoma cruzi infection and cognitive impairment in old age (the Bambuí Study)

BACKGROUND

Limited clinical data suggest that chronic Trypanosoma cruzi infection, which causes Chagas' disease (ChD), is associated with cognitive impairment. This study investigated this association in a large population-based sample of older adults.

METHODS

Participants in this cross-sectional study comprised 1,449 persons aged > or = 60 years from a Brazilian endemic area (Bambuí). Cognitive functioning was ascertained by the Mini-Mental State Examination (MMSE), considering its score in percentiles [< or =14 (<5th percentile), 15-22 (5th to <25th) and > or =23]. Hypothesized risk factors were T. cruzi infection, ChD-related electrocardiographic (ECG) abnormalities and use of digoxin medication. Potential confounders included depressive symptoms, smoking, stroke, hemoglobin, HDL cholesterol, blood glucose, systolic blood pressure, and use of psychoactive medication.

RESULTS

The prevalence of T. cruzi infection was 37.6%. There was a graded and independent association between infection and the MMSE score (adjusted odds ratios estimated by ordinal logistic regression = 1.99; 95% CI 1.43-2.76). No significant associations between the MMSE score and ECG abnormalities or digoxin medication use were found.

CONCLUSIONS

This study provides for the first time epidemiological evidence of an association between T. cruzi infection and cognitive impairment which was not mediated by either ChD-related ECG abnormalities or digoxin medication use.

The pattern of depressive symptoms and factor analysis of the Cornell Scale among patients in Norwegian nursing homes

BACKGROUND

Depression is more prevalent in subjects with dementia than in those without it. Due to both psychological and biological risk factors it is suggested that a bimodal distribution of depressive symptoms exists with higher prevalence rates being found among patients suffering both with mild and with severe dementia.

AIM

To confirm or reject the hypothesis of a bimodal distribution of depressive symptoms.

METHODS

A sample of 1,159 randomly selected nursing home patients was assessed using the Cornell Scale, the Clinical Dementia Rating Scale (CDR) and Lawton's Scale of the activities of daily living. Additionally, information was collected from the patients' records. A factor analysis of the Cornell Scale was performed.

RESULTS

The use of antidepressants and demographic characteristics, except for gender distribution, did not differ across CDR groups. Patients with dementia had more symptoms such as anxiety, irritability, agitation, retardation, loss of interest, lack of joy and delusion than those without dementia. No symptom was more frequent among non-demented subjects. The factor analysis resulted in a five factors solution: 'mood', 'cyclic', 'physical', 'retardation' and 'behavioural' factor. The score on the mood subscale did not differ across CDR groups (p = 0.326), whereas the scores on the four other subscales increased with increasing CDR scores (p < 0.001).

CONCLUSION

We did not find a bimodal distribution of depressive symptoms. The explanation for the occurrence of the typical core symptoms of depression, the mood symptoms, is probably complex. The non-mood symptoms are probably strongly influenced by biological factors.

Distinguishing between depression and dementia in older persons: neuropsychological and neuropathological correlates

Dementia and depression are frequently comorbid among older adult patients. Depression is related to cognitive decrement and can even represent the first signs of a neurodegenerative process. It can be difficult to distinguish depressed patients exhibiting the first signs of dementia from those whose cognition will improve with treatment. In this article, studies from the neuropsychological literature are reviewed that aid in accurate diagnosis and prognosis. Furthermore, the relationship between depression and dementia is explored by examining potential neurobiological mechanisms that may potentiate both syndromes in the context of the ongoing debate on depression as a prodrome and/or a risk factor for dementia. This article is concluded with suggestions for clinicians when deciding who to refer for neuropsychological assessment and with ideas for further research that might promote a better understanding of the complex association between depression and dementia during old age.

Best practices in care management for Asian American elders: the case of Alzheimer's disease

This article addresses practice concerns and special issues for professionals doing case management for older Asian Americans using Alzheimer's disease as the case example. Highlighted are cross-cultural issues in assessment for depression in this population, as well as caregiving and community service utilization issues. The research is based on the author's own work and the literature, as well as results from a population-based study of caregivers of the elderly in California.

Prevalence and predictors of depression in populations of elderly: a review

OBJECTIVE

To offer an update on prevalence and predictors of old age depression in populations of elderly Caucasians.

METHOD

The databases MEDLINE and Psychinfo were searched and relevant literature from 1993 onwards was reviewed.

RESULTS

The prevalence of major depression ranges from 0.9% to 9.4% in private households, from 14% to 42% in institutional living, and from 1% to 16% among elderly living in private households or in institutions; and clinically relevant depressive symptom 'cases' in similar settings vary between 7.2% and 49%. The main predictors of depressive disorders and depressive symptom cases are: female gender, somatic illness, cognitive impairment, functional impairment, lack or loss of close social contacts, and a history of depression.

CONCLUSION

Depression is frequent in populations of elderly. Methodological differences between the studies hinder consistent conclusions about geographical and cross-cultural variations in prevalence and predictors of depression. Improved comparability will provide a basis for consistent conclusions.

Cognitive assessment and differentiating the 3 Ds (dementia, depression, delirium)

Differentiation between a diminished or altered cognitive functioning asa consequence of aging and one resulting from serious health problems is critical in the elderly. An unrecognized cognitive disorder or the worsening of the impairment may hamper the effectiveness and appropriateness of care and treatment; therefore, standardized assessment procedures and systematic monitoring of cognition and behavior are important aspects of the nursing care. of older adults. In this article, current notions for accurate and comprehensive cognitive assessment in older persons are delineated. Further, an overview of epidemiological screening and diagnostic dilemmas of dementia, depression, and deliriumare provided.

Regional cerebral metabolism in early Alzheimer's disease with clinically significant apathy or depression

BACKGROUND

Alzheimer's disease (AD) is clinically characterized by cognitive impairment and behavioral disturbances. The aim of the study was to identify regional alterations in brain function associated with neuropsychiatric symptoms in early AD.

METHODS

Patients underwent measures of cerebral glucose metabolism applying positron emission tomography (PET) and (18)F-fluorodeoxyglucose. Neuropsychiatric symptoms were assessed using the Neuropsychiatric Inventory (NPI). Positron emission tomography images of patients suffering a neuropsychiatric symptom of clinical significance (NPI subscore for a specific item >/=4 points) were compared with the images of patients without the specific symptom under study (NPI subscore for a specific item = 0 points).

RESULTS

A total of 53 patients with AD (Mini-Mental State Examination [MMSE] 22.5 +/- 2.94 points) entered the study. Of all symptoms, apathy and depression were most frequently encountered. The patient group with apathy (n = 17) revealed significant decreases in left orbitofrontal regions when compared with patients free of apathy. Depression of clinical significance (n = 10) was associated with hypometabolism in dorsolateral prefrontal regions.

CONCLUSIONS

These findings support the notion that different functional circuits underlie apathy and depression in early AD.

Pain Treatment and Quality of Life

The purpose of this study was to identify implications for the care of nursing home residents based on exploration of the relationship of depression to pain, cognitive impairment, and communication impairment in this population. A descriptive, cross-sectional, post-hoc design was used. Methods of statistical analysis included bivariate correlation coefficient calculation, stepwise multiple regression, and analysis of variance. A complex triad of cognitive impairment, pain, and depression was identified. The strength of the relationship between depression and cognitive impairment increases as cognitive impairment increases and in the presence of pain. This relationship is strongest among residents with severe cognitive impairment, severe communication impairment, and advanced age. Nurses may be able to relieve symptoms of depression in nursing home residents by using strategies based on knowledge of the resident's cognitive, communication, and pain status. Treating pain may lead to improved cognitive performance in residents who are depressed or reduced depression in residents who are cognitively impaired. The most elderly adults and adults with severe communication impairment may benefit most from these interventions.

Lifetime symptoms of depression in Alzheimer's disease

INTRODUCTION

Depression is common in Alzheimer's disease (AD). The symptomatology of depression in dementia may differ from depression alone. Consequently, the reports on lifetime depressive symptoms were compared in AD patients and age-matched non-demented participants.

METHODS

Seventy-six AD patients, 109 elderly from the general population and their 189 siblings were examined using the Composite International Diagnostic Interview (CIDI). The presence of individual lifetime depressive symptoms was compared between 76 AD patients, 29 AD patients with comorbid depression, and different control groups using chi(2) statistics and logistic regression analysis.

RESULTS

Lifetime depressive symptoms were significantly more frequent in 76 AD patients than in 109 age-matched elderly from the general population. These 76 AD patients complained more about thinking and concentration disturbances, and less about depressed mood or appetite disturbance than the 298 non-demented participants matched for the lifetime presence of major depression (MD). In agreement, the 29 patients comorbid for lifetime diagnoses of AD and MD reported less about depressed mood than the 114 age-matched elderly with MD only. Feelings of worthlessness and suicidal ideas were related to the severity of cognitive decline.

CONCLUSION

AD influences the reports on lifetime depressive symptoms. This may be caused by additional neurodegeneration, by an overlap of symptoms of depression and dementia or by an altered perception of mood disturbances in AD. Further studies should investigate these alternatives.

Health care utilization in dementia patients with psychiatric comorbidity

PURPOSE

The purpose of this research was to determine if differences in service use exist between dementia patients with and without psychiatric comorbidity.

DESIGN AND METHODS

A retrospective cohort study was conducted on all Veterans Affairs (VA) beneficiaries seen at the Houston Veterans Affairs Medical Center with a VA Outpatient Clinic File diagnosis of dementia in 1997. The primary dependent measure was amount of Houston VA health service use from study entry until the end of fiscal year 1999 or until death.

RESULTS

Of the 864 dementia patients in the identified cohort, two thirds had a comorbid psychiatric diagnosis. Examination of 2-year health service use revealed that, after adjusting for demographic and medical comorbidity differences, dementia patients with psychiatric comorbidity had increased medical and psychiatric inpatient days of care and more psychiatric outpatient visits compared with patients without psychiatric comorbidity.

IMPLICATIONS

Further understanding of the current health service use of dementia patients with psychiatric comorbidity may help to establish a framework for considering change in the current system of care. A coordinated system of care with interdisciplinary teamwork may provide both cost-effective and optimal treatment for dementia patients.

Markers for depression in Parkinson's disease

OBJECTIVE

To assess whether general risk factors for depression are also markers of depression in patients with Parkinson's disease (PD) and to identify additional disease-specific markers.

METHOD

A two-step logistic regression was performed on data from 161 consecutively referred PD patients, 40 of whom suffered from major depressive disorder. A first logistic model was created with five general risk factors for depression. Next, five potential disease-specific markers were added to see whether this would improve the model.

RESULTS

The logistic model of general risk factors for depression also predicted depression in PD patients. A family history of depression was the most important marker. 'Right-sided onset' was the only disease-specific marker that improved the model.

CONCLUSION

Established risk factors for depression in the general population are also markers of depression in PD. The importance of correcting for general risk factors for depression in the search for disease-specific risk factors is stressed.

Assessment by nurses of mood, general behaviour and functional ability in patients with dementia receiving nursing home care

The aim of this study was to investigate the reliability of the Patient Mood Assessment Scale (PMAS), the General Behaviour Assessment Scale (GBAS) and the Gottfries Bråne Steen scale and to investigate mood, general behaviour, degree of dementia and symptoms for patients with dementia living permanently in nursing home care (n = 75). Interviews were conducted with the contact nurses, focussing on their view of the patients during the preceding week, based on the above-mentioned assessment scales. In 29 cases a second interview was conducted with another nurse in order to investigate the inter-rater reliability. The inter-rater reliability was high for items associated with ADL and intellectual functions, but low for items associated with emotional aspects. The nurses' difficulties in assessing the patients' emotional state could arise because these matters are not regularly discussed among the staff or could reflect the nurse's inner state rather than that of the patient. The varying understanding that the nurses had of the patients raises the question of whether the care provided is based on the nurses' opinions rather than on the patients' needs. There is a need for continuous and reflective discussions in the staff group, focusing on the patients' physical as well as emotional needs.

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

OBJECTIVE

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Efficacy of metrifonate in improving the psychiatric and behavioral disturbances of patients with Alzheimer's disease

Neuropsychiatric and behavioral symptoms are frequent and problematic components of Alzheimer's disease (AD). In two previously reported studies, metrifonate was shown to benefit behavioral symptoms as assessed by the Neuropsychiatric Inventory (NPI). In this post hoc analysis, detailed studies were completed to determine the effects of metrifonate on individual symptoms. This study was a retrospective analysis of pooled NPI data from two double-blind, placebo-controlled, multicenter 26-week studies of metrifonate that had achieved similar levels of cholinesterase inhibition. Mild-to-moderate probable AD patients received placebo (n = 222) or metrifonate (n = 450) 30 to 60 mg by weight or a 50-mg fixed dose once daily. At 26 weeks, metrifonate-treated patients had significantly reduced NPI total scores (P = .001) and fewer neuropsychiatric symptoms when compared with placebo-treated patients, including hallucinations (P = .004), agitation/aggression (P = .006), depression/dysphoria (P = .011), apathy (P = .019), and aberrant motor behavior (P = .008). Metrifonate reduced or stabilized neuropsychiatric disturbances in 60% of symptomatic patients. Almost 40% of metrifonate-treated patients had a clinically relevant reduction (> or = 30% decrease in NPI score) in their neuropsychiatric disturbances (P = .002). High proportions of metrifonate-treated patients manifested clinically relevant reductions in anxiety (58%, P = .009), apathy (51%, P = .020), and depression/dysphoria (50%, P = .021) compared to placebo. The metrifonate-associated reductions in NPI scores were evident by week 12 and were maintained for the 26-week study period. There was an overall effect size of metrifonate of approximately 15% on total NPI scores when compared to placebo. Metrifonate significantly reduced many of the psychiatric and behavioral symptoms of AD. The observations suggest that enhancement of cholinergic functions in AD has beneficial effects on behavior.

Depression, cognitive impairment and function in Alzheimer's disease

Depression is very common in patients with dementia but the relationship is very complex. Depression is regarded as a cause of excess disability in persons with dementia and contributes to their functional decline. The assessment of depression in dementia patients, however, has been difficult in that the validity of self-reported depression in patients with dementia has been questioned. This study was done to investigate whether self-reported depression by persons with dementia (using the GDS) is related to their functional abilities as rated by a family caregiver (using the IADL scale) above and beyond demographic variables. This study was conducted at the Detroit Satellite of the Michigan Alzheimer's Disease Research Center. There were 141 participants, 67% were African American and 33% were European American. Statistical analyses included a correlational and multiple regression approach to determine the predictive relationships of cognitive and depressive symptoms above and beyond the influence of demographic variables and cognition. The results of the study further support the notion that depression in dementia is significantly related to functional decline but, more importantly, that self-reported depression in patients with dementia can be valuable information in understanding patients' functioning.

Depressive symptoms and associated factors in a cognitively normal elderly population: the Tajiri Project

BACKGROUND AND OBJECTIVE

Since depression is one of the main problems of elderly subjects, it is important to examine the prevalence of this condition and to identify associated factors.

METHODS

A total of 1525 cognitively normal subjects aged 65 years and over in the town of Tajiri, a typical agricultural town in Japan, were analysed. Their MMSE (mini-mental state examination) scores were 24 or over. Depressive state was assessed by Zung's SDS (self-rating depression scale) with a comprehensive interview to examine ADL, demographics and symptoms associated with illness, etc. The prevalence of depression was calculated. To determine the factors associated with depression, the t-test and the Chi-square test were used. To examine the relative strength of each factor, logistic regression analysis was performed.

RESULTS

The ratio of the depressive subjects was 6.4%, lower than those of previous reports, probably due to the effect of excluding dementia subjects. The ratio for older females aged 80 years and over was 14.3%, which was significantly higher than that of the males. Among socio-demographic factors, sex, age, number of children and perception of economic status, were significantly related. For health status and ADL, such factors as perception of health and medical history of heart disease and rheumatism were related. For familial and social status, factors such as daily activity and several conversation abilities were related. The logistic regression analysis indicated that perception of health and daily activity were associated.

CONCLUSIONS

In this study, we isolated some factors related to depression in a cognitively normal population. Knowledge of such factors is important for appropriate mental care of aged subjects.

Longitudinal follow-up of depressive symptoms among normal versus cognitively impaired elderly

OBJECTIVES

This prospectively designed longitudinal study assesses prevalence, incidence and prognosis of depressive symptoms among cognitively normal elderly volunteers compared with patients with mild cognitive impairment (MCI), dementia of Alzheimer type (DAT), and vascular dementia (VAD). Possible relationships between depressive symptoms, cognitive performance, disease types, and effects of antidepressant treatment were analyzed.

METHODS

Two hundred and ninety four subjects exhibiting different levels of cognitive performance were admitted to this study. Demographics, cardiovascular and neurodegenerative risk factors, together with measures of neuropsychological test performance, were obtained at sequential visits. Depressive symptoms were selectively treated with antidepressant medications.

RESULTS

One hundred and forty six subjects with normal cognition, 19 subjects with MCI, 42 patients with DAT, and 32 patients with VAD were followed for a mean of 3.5 years. With the passage of time, there were trends showing prevalence of depressive symptoms to decrease among DAT and to increase among VAD patients. VAD patients exhibited the highest incidences of new-onset depressive symptoms, followed in incidence by DAT and MCI groups. Depressive symptoms among VAD and MCI patients were more persistent and refractory to antidepressant medications than for DAT patients. Trends suggested that antidepressant treatment might benefit MCI and VAD subjects more than DAT patients. Motivationally related depressive symptoms accounted for major components of elevated Hamilton depression rating scale scores.

CONCLUSIONS

Depressive symptoms among DAT patients have higher rates of spontaneous resolution, without requiring intensive drug treatment, than among VAD patients in whom depressive symptoms are more persistent and refractory to drug treatment. Early depressive symptoms among subjects with MCI may represent a preclinical sign and should be considered as a risk factor for impending DAT or VAD among the elderly.

Practice parameter: diagnosis of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology

OBJECTIVE

To update the 1994 practice parameter for the diagnosis of dementia in the elderly.

BACKGROUND

The AAN previously published a practice parameter on dementia in 1994. New research and clinical developments warrant an update of some aspects of diagnosis.

METHODS

Studies published in English from 1985 through 1999 were identified that addressed four questions: 1) Are the current criteria for the diagnosis of dementia reliable? 2) Are the current diagnostic criteria able to establish a diagnosis for the prevalent dementias in the elderly? 3) Do laboratory tests improve the accuracy of the clinical diagnosis of dementing illness? 4) What comorbidities should be evaluated in elderly patients undergoing an initial assessment for dementia?

RECOMMENDATIONS

Based on evidence in the literature, the following recommendations are made. 1) The DSM-III-R definition of dementia is reliable and should be used (Guideline). 2) The National Institute of Neurologic, Communicative Disorders and Stroke--AD and Related Disorders Association (NINCDS-ADRDA) or the Diagnostic and Statistical Manual, 3rd edition, revised (DSM-IIIR) diagnostic criteria for AD and clinical criteria for Creutzfeldt--Jakob disease (CJD) have sufficient reliability and validity and should be used (Guideline). Diagnostic criteria for vascular dementia, dementia with Lewy bodies, and frontotemporal dementia may be of use in clinical practice (Option) but have imperfect reliability and validity. 3) Structural neuroimaging with either a noncontrast CT or MR scan in the initial evaluation of patients with dementia is appropriate. Because of insufficient data on validity, no other imaging procedure is recommended (Guideline). There are currently no genetic markers recommended for routine diagnostic purposes (Guideline). The CSF 14-3-3 protein is useful for confirming or rejecting the diagnosis of CJD (Guideline). 4) Screening for depression, B(12) deficiency, and hypothyroidism should be performed (Guideline). Screening for syphilis in patients with dementia is not justified unless clinical suspicion for neurosyphilis is present (Guideline).

CONCLUSIONS

Diagnostic criteria for dementia have improved since the 1994 practice parameter. Further research is needed to improve clinical definitions of dementia and its subtypes, as well as to determine the utility of various instruments of neuroimaging, biomarkers, and genetic testing in increasing diagnostic accuracy.

Depressive symptoms among cognitively normal versus cognitively impaired elderly subjects

OBJECTIVES

The present cross-sectional study analyzed the prevalence and severity of depressive symptoms among patients with Alzheimer's disease (DAT), vascular dementia (VAD), and among the cognitively normal elderly. Putative risk factors contributing to depression were likewise evaluated.

METHODS

Seventy-six DAT patients, 51 VAD patients, and 121 cognitively normal subjects were admitted to the study. Questionnaires concerning demography and their vascular and familial risk factors together with results of neuropsychological testing by combined Mini-Mental Status Examinations (MMSE), Cognitive Capacity Screening Examinations (CCSE), and Hamilton Depression Rating Scales (HDRS) were obtained so that resulting data would be statistically analyzed.

RESULTS

Prevalence of depressive symptoms among VAD, DAT, and cognitively normal elderly were 31.4%, 19.9%, and 13.2%, respectively. 25.5% of VAD and 13.2% of DAT patients had depression of mild to moderate degrees. Regression analysis revealed that diagnosis of VAD and DAT, heart disease, and past history of depression was significantly associated with high HDRS scores. There was no correlation between degree of depression and severity of cognitive impairments.

CONCLUSION

Mild to moderate depression is a common comorbidity with organic dementia, especially VAD, but associated depression is independent of severity of cognitive impairments.

Neurobehavioral and neuropsychiatric symptoms in Alzheimer's disease: characteristics and treatment

Neuropsychiatric symptoms are common in Alzheimer's disease. Personality changes, mood disturbance, and psychosis are frequently seen and may coexist in the same patient. Neuropsychiatric symptoms may signal the onset of disease and often fluctuate and recur. These symptoms are associated with a more rapid cognitive and functional decline that can lead to institutionalization. Cholinergic therapy, disease-modifying therapy, and psychotropic medications can improve these symptoms.