Prevalence of depression in an elderly population in Finland

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.

Aetiology of late-life depression

Depressive disorder has no single cause. Arguably, in old age it is a more heterogeneous condition than in earlier adult life, in both clinical presentation and causation. A broad distinction is often made between early- and late-onset depression in later life. The aetiology of these may differ and is currently the subject of new research.

High Sensitivity of Aged Mice to Deoxynivalenol (Vomitoxin)-Induced Anorexia Corresponds to Elevated Proinflammatory Cytokine and Satiety Hormone Responses

Deoxynivalenol (DON), a trichothecene mycotoxin that commonly contaminates cereal grains, is a public health concern because of its adverse effects on the gastrointestinal and immune systems. The objective of this study was to compare effects of DON on anorectic responses in aged (22 mos) and adult (3 mos) mice. Aged mice showed increased feed refusal with both acute i.p. (1 mg/kg and 5 mg/kg) and dietary (1, 2.5, 10 ppm) DON exposure in comparison to adult mice. In addition to greater suppression of food intake from dietary DON exposure, aged mice also exhibited greater but transient body weight suppression. When aged mice were acutely exposed to 1 mg/kg bw DON i.p., aged mice displayed elevated DON and DON3GlcA tissue levels and delayed clearance in comparison with adult mice. Acute DON exposure also elicited higher proinflammatory cytokine and satiety hormone responses in the plasma of the aged group compared with the adult group. Increased susceptibility to DON-induced anorexia in aged mice relative to adult mice suggests that advanced life stage could be a critical component in accurate human risk assessments for DON and other trichothecenes.

Psychotic major depression in older people: a systematic review

OBJECTIVE

This study aimed to systematically review available evidence relevant to the following issues: (1) whether psychotic major depression (PMD) in older people differs in overall severity from non-PMD, besides the presence of psychotic symptoms; (2) whether it constitutes a distinct clinical entity from non-PMD; and (3) whether it differs from PMD in younger adults.

DESIGN

A computerized MEDLINE, PsycINFO and the entire Cochrane Library search has been performed in June 2013 for prospective controlled studies investigating PMD features in older people.

RESULTS

Thirty-five relevant studies were identified. PMD in older people compared with non-PMD has been shown to present with overall more severe depressive symptomatology, more psychomotor disturbance, more guilt feelings, more depressive episodes with psychosis, worse prognosis, more severe executive dysfunction associated with frontal lobe atrophy, and lower serum dopamine β-hydroxylase activity. No differences in the efficacy of an antidepressant plus antipsychotic combination versus antidepressant monotherapy in the acute treatment as well as in the maintenance treatment were found. PMD in older patients is characterized by more somatic complaints and delusions of hypochondriacaland impending disaster content and by a lower comorbidity with anxiety disorders compared with PMD in younger adults.

CONCLUSIONS

Psychotic major depression in older people is associated with higher severity in most clinically important key features than in non-PMD. However, available evidence is still insufficient for the conclusive elucidation of its nosological status. Finally, the differences between PMD in older and younger patients can be attributed to biological and psychosocial changes of old age.

Prevalence of major chronic conditions among older Chinese adults: the Study on Global AGEing and adult health (SAGE) wave 1

Background

The likely corresponding increase in prevalence of chronic disease will be a major challenge for the health care system. Few nationwide epidemiological studies include a large enough sample of older adults to provide estimates of chronic conditions in the older adult population. This study aimed to estimate the prevalence of eight common chronic health conditions and examine socioeconomic inequalities in the diseases among older adults in China.

Method

Data are from SAGE-China Wave 1, including 13,157 people aged 50-plus years. Respondents were asked if they had been diagnosed with any of the following chronic medical conditions: angina, arthritis, asthma, stroke, diabetes, depression, chronic lung disease and hypertension. A set of validated symptom-based questions and related diagnostic algorithms were also used to estimate disease prevalence for angina, arthritis, asthma and depression. Multivariate logistic regression was performed to examine the probability of developing chronic conditions in relation to sociodemographic variables such as gender, age, urban/rural setting and household wealth level.

Results

Fifty percent of respondents reported having one of the selected chronic conditions, 18.9% two conditions, 5.8% three conditions, and 1.4% reported having four or more chronic conditions. Self-reported prevalence was generated for angina (8%), arthritis (22%), asthma (2%), stroke (3%), diabetes (7%), depression (0.3%), chronic lung disease (8%) and hypertension (27%). The symptom-based prevalence of angina, arthritis, asthma and depression was 10%, 20%, 4% and 2%, respectively.

Conclusion

This study provides the best available prevalence estimates for major chronic health conditions among older Chinese adults. Findings from this study indicated that major chronic conditions were common, so prevention and early intervention targeting adults aged 50 years and older should be prioritized.

Correlates of self-reported depressive symptoms: a study of older persons of Punjab, Pakistan

This paper examines the prevalence and correlates of depressive symptoms among older persons of Punjab, the largest Province of Pakistan. Data were gathered from 4191 older persons aged 60+ using Probability Proportional to Size (PPS) of population. A version of the CES-D Scale adapted for low-literate populations was used to measure self reported depressive symptoms. Various independent factors, including socioeconomic factors, self-reported health conditions, and functional impairments were examined to see their net effect on depressive symptoms among older persons. Results of logistic regression analysis showed that region, area, living index, independent source of income, self-reported health conditions, and functional impairment were significant factors affecting self-reported depressive symptoms among older persons in Punjab. An important cross-cultural difference was a lower risk of depressive symptoms among older women, which may reflect the buffering effects of family co-residence and the position of seniors in extended families.

Age and risk for depression among the elderly: a meta-analysis of the published literature

OBJECTIVE

The goal of this study was to determine the relationship between age and risk for depression among the old and the oldest old. Method MEDLINE, EMBASE, and the Cochrane Library database were used to identify potential studies. The studies were divided into cross-sectional and longitudinal subsets. For each study, the numbers of the total participants, cases (for cross-sectional study), or incident cases (for longitudinal study) of depression in each age group were extracted and entered into Review Manager 4.2 software. Qualitative meta-analyses of cross-sectional studies and of longitudinal studies were performed. For prevalence and incidence rates of depression, odds risk (OR) and relative risk (RR) were calculated, respectively.

RESULTS

The qualitative meta-analyses showed that, compared with younger participants (above vs. below 65 years, above vs. below 70 years, above vs. below 75 years, and above vs. below 80 years), older age groups had a significantly higher risk for depression. (All of the ORs and RRs were significant.) Compared with participants aged 55-89, those aged above 90 years had no higher risk for depression. (Neither the OR nor the RR was significant.)

CONCLUSIONS

Despite the methodological limitations of this meta-analysis, older age appears to be an important risk factor for depression in the general elderly population (aged below 80 years), but not in the oldest population (aged above 85 years).

Living arrangements and risk for late life depression: a meta-analysis of published literature

OBJECTIVE

The goal of this study was to determine the relationship between living arrangements and risk for depression among older people.

METHOD

MEDLINE, EMBASE, The Cochrane Library database was used to identify potential studies. The studies were divided into cross-sectional and longitudinal subsets. Qualitative meta-analysis of the cross-sectional studies and longitudinal studies was performed, respectively. For prevalence and incidence rates of depression, odds ratio (OR) and relative risk (RR) were calculated, respectively.

RESULTS

The qualitative meta-analysis showed that older people living alone had a higher risk of depression than those not living alone (OR: 1.44; 95% confidence interval [95% CI]: 1.04-1.99); Relative risk (RR: 1.27, 95% CI: 0.89-1.80) and those living with families (OR: 2.59, 95% CI: 1.60-4.20). Older people living in a nursing home (OR: 2.90, 95% CI: 0.94-8.94; RR: 1.94, 95% CI: 1.18-3.20) or institutionalized setting (OR: 1.86, 95% CI: 1.37-2.52; RR: 2.03, 95% CI: 1.12-3.70) had a higher risk of depression than those living in home.

CONCLUSIONS

Despite the methodological limitations of this meta-analysis, living arrangements appear related to the risk for depression in the older population. Older persons living alone, in a nursing home, or in an institutionalized setting have higher risk for depression.

Elderly sexual offenders: two unusual cases

The aim of this case report is to describe two cases of sexual abuse by elderly subjects for which the Judge commissioned an expert psychiatric-forensic opinion. The elderly are generally believed to commit nonviolent crimes, whereas the two cases we observed feature forcible rape committed by elderly offenders, who showed no form of mental disease and had rationally planned their offense. They had never previously committed similar acts and had no history of homosexuality; both had been married for many years before the death of their wives and had adult children. Finally, no previous episodes of rape emerged in their personal histories during interrogations. The sociocultural context in which the crimes were committed was identical and arouses interest as regards both the method employed and how the crimes were discovered. The legal authorities then commissioned accurate investigations including medicolegal and psychiatric-forensic evaluations of the offenders and their victims.

Prevalence of depression and depressive symptoms among older Japanese people: comorbidity of mild cognitive impairment and depression

BACKGROUND

The aim of the study was to estimate the prevalence of DSM-III-R major depressive episodes (MDEs), depressive symptoms cases (DSCs) (defined as a score of ≥6 on the Geriatric Depression Scale but falling short of MDE), and coexisting mild cognitive impairment (MCI) among Japanese community-dwelling older people.

METHODS

Prevalence was estimated based on screening evaluation, individual interviews, and door-to-door visits. MDE and DSC were diagnosed, and the cognitive status of the participants was determined to be dementia, MCI, or normal.

RESULTS

A total of 1888 subjects of 2698 candidates (70.0%) participated. The prevalence of MDE and DSC were estimated to be 4.5% (95% CI, 3.4-6.0) and 11.5% (95% CI, 4.2-28.0), respectively. MCI was more prevalent in subjects with depression (26.2%) than those with normal mood (17.9%). Although no prototypical profile of cognitive dysfunction was revealed, multiple MCI was more prevalent in subjects with depression (12.2%) than subjects with normal mood (3.8%). Conversely, subjects with MCI (26.3%) were more likely to develop depression compared with those with normal cognitive function (18.0%).

CONCLUSIONS

The prevalence of depression in our subjects seems to be similar with that of previous studies. MCI was more prevalent in subjects with depression than those with normal mood. Individuals with depression showed no particular association with any of the four MCIs. Given that depression and MCI are often associated with each other and that MCI is a predictor for development of dementia, the risk of developing dementia in the depressed older people with coexisting MCI should be acknowledged.

Admixture analysis of age at onset in major depressive disorder

OBJECTIVES

This study aimed to determine the distributions of the age at onset (AAO) in patients with major depressive disorder (MDD) using admixture analysis and to determine the clinical differences between subgroups with different AAO.

METHODS

Participants were administered the Mini-International Neuropsychiatric Interview to obtain clinical data. Admixture analysis was performed using the STATA module DENORMIX to identify subgroups characterized by differences in AAO.

RESULTS

The best fit model was the three-component model with the following means, standard deviations and proportions: 14.60 (3.75) years (49.1%), 29.15 (6.75) years (34.1%) and 46.96 (6.06) years (16.8%) (χ(2)=3.64, 2 df, P=.162). The three subgroups were divided by AAO of 22 and 40. After controlling for duration of illness, there were no significant differences between the three AAO subgroups in terms of gender and psychiatric family history. However, the early-onset subgroup was significantly more likely to report being single compared to the intermediate- and late-onset groups. The proportion of individuals meeting criteria for lifetime comorbid panic disorders and obsessive-compulsive disorder did not differ significantly between the AAO groups. However, the early-onset group reported a higher incidence of attention-deficit/hyperactivity disorder (5.1% vs. 1.7% and 1.2%, P=.086), although this was not statistically significant.

CONCLUSIONS

Our study identified three characteristically different AAO subgroups in individuals suffering from MDD. The subgroups may reflect different underlying neurobiological mechanisms involved.

Marital Status and Risk for Late Life Depression: A Meta-Analysis of the Published Literature

This study assessed the relationship between marital status and the risk for depression in people ≥ 55 years old. Using the Medline™, EMBASE™ and Cochrane Library databases, clinical studies that published data on the association between marital status and risk of depression among individuals aged ≥ 55 years were identified. A quantitative meta-analysis of 24 cross-sectional and eight longitudinal studies was performed. Compared with married elderly people, unmarried elderly people had a higher risk for depression (odds ratio [OR], 1.55; relative risk [RR], 1.36). Compared with married elderly people, the widowed elderly people (OR 1.49; RR 1.71), divorced people (RR 2.14) and never-married people (OR 1.32) had a higher risk for depression. Among elderly unmarried people, widowed people had a higher risk for depression than those who never married (OR 1.51). In conclusion, being unmarried was an important risk factor for depression in elderly people.

Education and risk for late life depression: a meta-analysis of published literature

OBJECTIVE

Less education is commonly viewed as an important risk factor for late life depression. However, this has still not been confirmed. The goal of this study was to determine the relationship between education and risk for depression among the old.

METHOD

MEDLINE, EMBASE, and The Cochrane Library database were used to identify potential studies. The studies were divided into cross-sectional and longitudinal subsets. The qualitative meta-analysis of cross-sectional studies and that of longitudinal studies were preformed, respectively. For prevalence and incidence rates of depression, odds risk (OR) and relative risk (RR) were calculated, respectively.

RESULTS

Twenty-four cross-sectional and 12 prospective longitudinal studies were included in this review. In this meta-analysis, in the more and less education groups, there were 22,964 and 28,024 subjects and 3032 and 6462 cases of depression, respectively. The qualitative meta-analysis showed that, compared with old people with more education, those with less education had higher risk for depression (odds risk (OR): 1.58, 95% confidence intervals (95% CI): 1.38-1.82; Relative risk (RR): 1.49, 95% CI: 1.16-1.91).

CONCLUSIONS

Despite the methodological limitations of this meta-analysis, less education is associated with increase risk of late life depression.

Clinically significant depressive symptoms and associated factors in community elderly subjects from Sao Paulo, Brazil

OBJECTIVES

To determine the frequency of clinically significant depressive symptoms (CSDS) in a community sample of Brazilian elderly and to assess their relationship with sociodemographic factors, cognitive and functional impairment (CFI), and clinical diseases.

DESIGN

Cross-sectional study of a community-based sample of elderly subjects.

SETTING

City of Sao Paulo, State of Sao Paulo, Brazil.

PARTICIPANTS

A total of 1,563 elderly subjects aged 60 years or older.

MEASUREMENTS

A 10-item scale for screening of depressive symptoms in elderly people (D-10), the Mini Mental State Examination, the Fuld Object Memory Evaluation, the Informant Questionnaire on Cognitive Decline in the Elderly, the Bayer Activities of Daily Living Scale, and a sociodemographic and clinical questionnaire.

RESULTS

The frequency of CSDS was 13.0%. Univariate analysis identified independent factors associated with these symptoms in our sample. Logistic regression analysis indicated that being female, brown skinned, previously depressed, having CFI, using psychotropics, and not practicing physical exercise were related to CSDS. On the other hand, being older, clinically sick, employed, or married were not associated with CSDS.

CONCLUSIONS

: Consistent with previous reports, female gender, lack of physical activity, and CFI were significantly associated with higher frequencies of CSDS. Further investigations are necessary to clarify the occurrence of depression and possible modifiable factors in developing countries such as Brazil.

Co-occurring depressive symptoms in the older patient with schizophrenia

Clinicians treating older patients with schizophrenia are often challenged by patients presenting with both depressive and psychotic features. The presence of co-morbid depression impacts negatively on quality of life, functioning, overall psychopathology and the severity of co-morbid medical conditions. Depressive symptoms in patients with schizophrenia include major depressive episodes (MDEs) that do not meet criteria for schizoaffective disorder, MDEs that occur in the context of schizoaffective disorder and subthreshold depressive symptoms that do not meet criteria for MDE. Pharmacological treatment of patients with schizophrenia and depression involves augmenting antipsychotic medications with antidepressants. Recent surveys suggest that clinicians prescribe antidepressants to 30% of inpatients and 43% of outpatients with schizophrenia and depression at all ages. Recent trials addressing the efficacy of this practice have evaluated selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, sertraline, fluvoxamine and citalopram. These trials have included only a small number of subjects and few older subjects participated; furthermore, the efficacy results have been mixed. Although no published controlled psychotherapeutic studies have specifically targeted major depression or depressive symptoms in older patients with schizophrenia, psychosocial interventions likely play a role in any comprehensive management plan in this population of patients.Our recommendations for treating the older patient with schizophrenia and major depression involve a stepwise approach. First, a careful diagnostic assessment to rule out medical or medication causes is important as well as checking whether patients are adherent to treatments. Clinicians should also consider switching patients to an atypical antipsychotic if they are not taking one already. In addition, dose optimization needs to be targeted towards depressive as well as positive and negative psychotic symptoms. If major depression persists, adding an SSRI is a reasonable next step; one needs to start with a low dose and then cautiously titrate upward to reduce depressive symptoms. If remission is not achieved after an adequate treatment duration (8-12 weeks) or with an adequate dose (similar to that used for major depression without schizophrenia), switching to another agent or adding augmenting therapy is recommended.We recommend treating an acute first episode of depression for at least 6-9 months and consideration of longer treatment for patients with residual symptoms, very severe or highly co-morbid major depression, ongoing episodes or recurrent episodes. Psychosocial interventions aimed at improving adherence, quality of life and function are also recommended. For patients with schizophrenia and subsyndromal depression, a similar approach is recommended.Psychosis accompanying major depression in patients without schizophrenia is common in elderly patients and is considered a primary mood disorder; for these reasons, it is an important syndrome to consider in the differential diagnosis of older patients with mood and thought disturbance. Treatment for this condition has involved electroconvulsive therapy (ECT) as well as combinations of antidepressant and antipsychotic medications. Recent evidence suggests that combination treatment may not be any more effective than antidepressant treatment alone and ECT may be more efficacious overall.

Prevalence of clinically significant depressive symptoms in an epidemiologic sample of community-dwelling elders with milder forms of cognitive impairment in Hong Kong SAR

BACKGROUND

Depression and cognitive impairment in later-life have great bearings on public health. The two conditions often co-occur and have mutual implications on short-term risk and long-term prognosis.

METHOD

A two-phase epidemiologic survey on the prevalence of dementia in elders aged 60 and over was conducted in Hong Kong in 2005-2006. In the first phase, 6,100 randomly selected community dwelling elders were assessed with Cantonese version of Mini-Mental State Examination (C-MMSE) and Abbreviated Memory Inventory for Chinese (AMIC). Two thousand and seventy-three subjects were screened positive and invited for second phase cognitive and psychiatric assessment. 35.5% of screen-positive subjects participated in Phase 2 assessment conducted by psychiatrists for diagnosis of dementia. Severity of dementia was determined using Clinical Dementia Rating Scale (CDR). Cornell Scale for Depression in Dementia (CSDD) and a structured bedside cognitive battery were also administered to each subject.

RESULTS

1.7% of subjects with CDR 0.5 and 5.9% of subjects with CDR 1 had clinically significant depressive symptoms (>or= 8 on CSDD). Score on CSDD correlated positively with duration of cognitive symptoms, scores on CIRS and CMMSE in linear regression model. In a logistic regression model, male gender, duration of cognitive symptoms, CIRS and CMMSE was associated with increased risk for clinically significant depressive symptoms.

CONCLUSIONS

In our sample, milder forms of cognitive impairment were associated with increased risk for depression in the presence of other risk factors such as male gender, higher physical illness burden and longer duration of cognitive symptoms.

Prevalence and predictors of depression among an elderly population of Pakistan

OBJECTIVE

To assess the magnitude and risk factors of the problem of depression in an elderly population of Pakistan.

METHOD

A cross-sectional study was conducted using a sample of 402 people aged 65 and above visiting the Community Health Center of the Aga Khan University, Karachi. Questionnaire based interviews were conducted for data collection and the 15-Item Geriatric Depression Scale was used to screen for depression. Univariate and multivariate logistic regression analyses were performed to identify factors associated with depression.

RESULTS

Of the 402 participants; 69.7% (95% CI=+/-4.5%) were men, 76.4% (95% CI=+/-4.2%) were currently married, 36.8% (95% CI=+/-5%) had received 11 or more years of education and 24.4% (95% CI=+/-4.2%) were employed. The mean age was 70.57 years (SD=+/-5.414 years). The prevalence of depression was found to be 22.9% (95% CI=+/-4.1%) and multiple logistic regression analysis indicated that higher number of daily medications (p-value=0.03), total number of health problems (p-value=0.002), financial problems (p-value<0.001), urinary incontinence (p-value=0.08) and inadequately fulfilled spiritual needs (p-value = 0.067) were significantly associated with depressive symptoms.

CONCLUSION

We have identified several risk factors for depression in the elderly which need to be taken into account by practicing family physicians and health care workers.

Higher burden of depression among older women: the effect of onset, persistence, and mortality over time

CONTEXT

The prevalence of depression is disproportionately higher in older women than men, yet the reasons for this sex difference are not clear.

OBJECTIVE

To determine whether the higher burden of depression among older women than men might be attributable to sex differences in the onset (ie, first or recurrent episodes) or persistence of depression and/or to differential mortality among those who are depressed.

DESIGN

Prospective cohort study.

SETTING

General community in greater New Haven, Connecticut, from March 23, 1998, to August 31, 2005.

PARTICIPANTS

A total of 754 persons, 70 years or older, who were evaluated at 18-month intervals for 72 months.

MAIN OUTCOME MEASURES

The 3 outcome states were depressed, nondepressed, and death, with scores of 20 or more and less than 20 on the Center for Epidemiological Studies Depression Scale denoting depressed and nondepressed, respectively. The association between sex and the likelihood of 6 possible transitions (namely, from nondepressed or depressed to nondepressed, depressed, or death) was evaluated over time.

RESULTS

The prevalence of depression was substantially higher among women than men at each of the 5 time points (P < .001). In most cases, transitions between the nondepressed and depressed states were characterized by moderate to large absolute changes in depression scores (ie, > or = 10 points). Adjusting for other demographic characteristics, women had a higher likelihood of transitioning from nondepressed to depressed (odds ratio, 2.02; 95% confidence interval, 1.39-2.94) and a lower likelihood of transitioning from depressed to nondepressed (odds ratio, 0.27; 95% confidence interval, 0.13-0.56) or death (odds ratio, 0.24; 95% confidence interval, 0.09-0.60).

CONCLUSION

Among older persons, the higher burden of depression in women than men seems to be attributable to a greater susceptibility to depression and, once depressed, to more persistent depression and a lower probability of death.

Geriatric depression and cognitive impairment

Cognitive impairment is common in geriatric depression, and depressed individuals with co-morbid cognitive impairment are at increased risk for a number of adverse medical, psychiatric and cognitive outcomes. This review focuses on clinical issues surrounding the co-occurrence of these two conditions within the context of current research. We (1) review the clinical criteria and prevalence of depression, as well as co-morbid cognitive impairment, (2) discuss factors associated with persistent cognitive impairment in depression, including dementia, and (3) review research relevant to the assessment and treatment of cognitive impairment and dementia in the context of depression. We conclude that current research on depression and cognition can inform clinical decisions that reduce the occurrence of adverse outcomes. Clinicians are encouraged to develop proactive approaches for treatment, which may include combinations of pharmacological and psychotherapeutic interventions.

Prevalence of depressive symptoms and related risk factors for depressive symptoms among elderly persons living in a rural Japanese community: a cross-sectional study

To clarify the prevalence of depression in a rural community in Japan and to evaluate the social and familial risk factors for depression, with the goal of suicide prevention, a questionnaire survey was conducted on a total of 2,763 elderly persons. The determined prevalence of depressive symptoms (Zung's self-rated depression scale score of 50 points or more) was 10.4%. Logistic regression analysis showed associations between depressive symptoms and age, absence of a friendly companion, irritation with one's family, frequent loneliness, the opinion that stress has a large impact on one's life, suicide ideation, and poor subjective physical and mental health.

Underlying factors in the association between depressed mood and mobility limitation in older people

BACKGROUND

Depressed mood may either precede mobility limitation or follow from mobility limitation.

OBJECTIVE

To compare mood status among people with manifest mobility limitation, those with preclinical mobility limitation and those without mobility limitation and investigate factors explaining the association between depressed mood and mobility limitation.

DESIGN

Cross-sectional.

SUBJECTS

645 community-living 75- to 81-year-old people.

METHODS

Depressed mood was assessed using the Centre for Epidemiologic Studies Depression Scale (CES-D, cut-off score 16); difficulty walking 500 m was assessed by self-report. Those reporting difficulty were categorised as having manifest mobility limitation. Those with no difficulty but reporting task modifications, such as reduced frequency of walking, were categorised as having preclinical mobility limitation. The association between depressed mood and mobility limitation was analysed using logistic regression analysis with gender, age, economic situation, the availability of a confidant, chronic conditions, and widespread pain as covariates.

RESULTS

Depressed mood was found in 34% of subjects with manifest mobility limitation, in 26% of those with preclinical mobility limitation, and in 13% of those without mobility limitation. The unadjusted odds ratio for depressed mood was 3.43 (95% CI 2.04-5.76) among subjects with manifest mobility limitation and 2.38 (95% CI 1.52-3.73) among those with preclinical mobility limitation, compared to those without mobility limitation. Adjustment for covariates reduced the risks to 2.10 (95% CI 1.15-3.82) and 1.99 (95% CI 1.24-3.20), respectively. Widespread pain explained 28% of the increased risk of depressed mood among those with manifest mobility limitation.

CONCLUSION

The dose-response relationship between depressed mood and mobility limitation suggests that both conditions may progress simultaneously and may share aetiology, at least in part. Pain may be an underlying factor in both depressed mood and mobility limitation.

The state of mental health in old-age across the 'old' European Union-- a systematic review

OBJECTIVE

The paper provides the first syllabus on the prevalence of mental disorders in old-age focusing on surveys conducted in the 15 countries, which comprised the 'old' European Union.

METHOD

A systematic search of the literature published from 1990 onwards was conducted.

RESULTS

Mental disorders in old-age are common. The most serious threats to mental health in old-age are posed by dementia and depression. It is a clear cut finding that dementia exponentially increases with age. The basic issue of whether depression increases or decreases with age remains unsolved. Databases on substance use, mild cognitive impairment, psychotic syndromes, anxiety, and somatoform disorders in old-age are much smaller, making conclusions difficult to draw.

CONCLUSION

Numerous questions in the field remain to be answered. Concerted action is needed to produce comparable data across Europe.

Physical and psychological functioning of daily living in relation to physical activity. A longitudinal study among former elite male athletes and controls

BACKGROUND AND AIMS

Physical exercise plays an important role in the prevention and reduction of disabilities in elderly people. The aim of this study was to determine the role of physical activity in the physical and psychological functioning of daily living in a cohort of former elite male athletes representing different sports, and controls of middle and old age.

METHODS

Subjects were 664 former elite male athletes (mean age 64.4 years) and 500 controls (62.0 years) in middle and old age. Subjects were mailed "Physical activity and health survey" questionnaires in 1985 and 1995. The primary outcomes the physical and psychological functioning of daily living--were assessed in 1995 using items from the Mini-Finland Health Survey. Logistic regression was used for longitudinal as well as cross-sectional analyses to estimate odds ratios (OR) for poor physical and psychological functioning of daily living in relation to recreational physical activity adjusted for age, sport group, life-style, BMI, mood, chronic diseases, personality characteristics, life-events and socio-economic status.

RESULTS

In the longitudinal analysis, low levels of physical activity (lowest MET quintile vs highest quintile) in 1985 (OR 4.91, 95% confidence interval (CI) 2.02-11.9), older age (> or =70 yrs vs under 60 yrs OR 9.93, 95% CI 4.90-20.2), depression (OR 2.03, 95% CI 1.01-4.09) and anxiety in 1995 (OR 2.67, 95% CI 1.34-5.32) increased the risk of poor physical functioning of daily living in 1995, whereas an increase in a physical activity between 1985-1995 (OR 0.89, 95% CI 0.83-0.95) protected against poor physical functioning of daily living. A history of participating in specific types of sports, especially among certain power sports (weight-lifting and track & field throwers) (OR 0.19, 95% CI 0.06-0.60) and team sports (OR 0.34, 95% CI 0.15-0.81) did reveal a significant protective effect against poor psychological functioning of daily living in the longitudinal analysis.

CONCLUSIONS

This study suggests that an increase in physical exercise supports physical daily functionality. A specific history of sports participation promotes psychological well-being at an older age.

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

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

Effects of a health advocacy, counselling, and activation programme on depressive symptoms in older coronary heart disease patients

OBJECTIVES

To describe the effects of a health advocacy, counselling, and activation programme on depressive symptoms among older coronary heart disease (CHD) patients.

METHODS

A randomised, controlled intervention study in Lieto, South-western Finland. Older (65 years and older) patients with CHD were randomly divided into an intervention group (IG) (n = 116) and a control group (CG) (n = 106). Outcome measures comprised changes in depressive symptoms (Zung Self-rating Depression Scale, ZSDS).

RESULTS

Depressive symptoms tended to decrease in IG and to increase in CG among men scoring 45 ZSDS sum points or more at baseline. The differences of the changes between IG and CG were significant in favour of IG. No similar changes were found among women.

CONCLUSIONS

A health advocacy, counselling, and activation programme aimed to increase knowledge about CHD, social activities, contacts, roles, support, and exercising was effective in reducing depressive symptoms among male CHD patients suffering from a moderate or high amount of depressive symptoms.

Électroconvulsivothérapie, utilité dans la dépression sévère du sujet de plus de 65 ans

The management of depression in subjects aged over 65 is based on the isolated or combined use of antidepressant chemotherapy, psychotherapy and electroconvulsive therapy. Electroconvulsive therapy, under general anaesthesia and use of curare, consists in producing a generalised seizure using a short, pulsed, electrical current administered via the transcranial route. There is renewed interest in electroconvulsive therapy with the development of specific rules and conditions for its use, together with the recruitment of depressed patients resistant to classical treatments in hospital settings. The efficacy of electroconvulsive therapy has been demonstrated in the elderly. The immediate side effects, related to the electrical stimulation and the seizure, such as headaches, nausea, confusion, and transient amnesia, regress within a few minutes or hours after the session. The limits of electroconvulsive therapy are the high risk of relapse on suspension of the sessions, relapse basically related to the severity of the depression. Consolidation electroconvulsive therapy provides new hope for better control of such relapses.

Depression in the elderly: new concepts and therapeutic approaches

Depression is one of the leading causes of suffering in the elderly, but it is often under-diagnosed and under-treated, partly due to the false belief that depression is a common aspect of aging. Depression in the elderly is frequently comorbid with medical illnesses, may often be expressed by somatic complaints, and may be a risk factor for other diseases such as dementia and coronary artery disease. Depression decreases the quality of life and increases disability and the risk of mortality, also due to suicide. Although several effective antidepressant drugs are available, with a favorable therapeutic index, non-pharmacological treatments, such as psychotherapy and exercise, should receive greater attention, since combination therapy is probably more effective.

Reduced mobility and physical activity as predictors of depressive symptoms among community-dwelling older adults: an eight-year follow-up study

BACKGROUND AND AIMS

Epidemiological research suggests that reduced physical activity and mobility may be associated with depressive symptoms. The present study examines the relative roles of mobility status and physical activity as predictors of depressive symptoms among community-dwelling older adults.

METHODS

The subjects comprised randomly selected, non-institutionalized residents of the city of Jyväskylä, central Finland, born in 1904-1923. At baseline, 80% (N = 1224) and after the 8-year follow-up period (1996) 88% (N = 663) of eligible persons were interviewed. All non-institutionalized men and women (N = 384) who participated in both baseline and follow-up interviews, who supplied data on the main questions of interest and who had no depressive symptoms at baseline, were selected for analysis. Depressive symptoms were assessed using the Finnish modified version of Beck's 13-item depression scale (RBDI). Physical activity was assessed on a seven-point scale. Mobility status was defined as the ability to walk two kilometers and climb one flight of stairs.

RESULTS

Subjects who were mobility-disabled and had a sedentary life-style had a higher risk (OR = 2.44) for depressive symptoms at follow-up than those who had good mobility and were physically active. The risk was also higher (OR = 1.99) in those who were mobility-disabled and had a physically active life-style, compared with physically active individuals with intact mobility. Those with good mobility had fewer depressive symptoms than those who had mobility problems, irrespective of the level of physical activity. No significant interaction was observed between physical activity and mobility in predicting the development of depressive symptoms. Older age significantly increased, and the number of chronic illnesses tended to increase the risk of developing depressive symptoms during the follow-up period. Gender and length of education were not significant predictors of depressive symptoms.

CONCLUSIONS

Mobility problems and older age seem to increase the risk for developing depressive symptoms in elderly people. The risk is not associated with the level of physical activity.

Long-term changes in mood of an aged population: repeated Zung-tests during a 10-year follow-up

Associates and predictors of lowered mood were investigated in a 10-year prospective study of 411 random persons of three birth cohorts (aged 75, 80 and 85 years) in Helsinki, Finland. High Zung-score ( > 45 points = lowered mood) was found in 24% of subjects and clearly associated with age. Lowered mood was also associated with pessimistic attitudes towards life and impaired survival prognosis. The mean Zung-score fell drastically during the first follow-up (from 39.1 to 34.6 points, P < 0.001) and remained unchanged thereafter at 10-year examination of the survivors (33.9 points). Lowering mood (increase in Zung-score) was best predicted by low baseline Zung-score (r = -0.673, P < 0.001), high baseline MMSE-score (r = -159. P < 0.05) and simultaneous changes in MMSE-scores (r = 0.269, P < 0.01). The data show that lowered mood is associated with pessimistic attitudes towards life, cognitive impairment and impaired survival and that cognitive impairment exposes a patient to lowering mood. It is possible that a screening program improves the mood of aged population.

Depression in late life: review and commentary

Depression is perhaps the most frequent cause of emotional suffering in later life and significantly decreases quality of life in older adults. In recent years, the literature on late-life depression has exploded. Many gaps in our understanding of the outcome of late-life depression have been filled. Intriguing findings have emerged regarding the etiology of late-onset depression. The number of studies documenting the evidence base for therapy has increased dramatically. Here, I first address case definition, and then I review the current community- and clinic-based epidemiological studies. Next I address the outcome of late-life depression, including morbidity and mortality studies. Then I present the extant evidence regarding the etiology of depression in late life from a biopsychosocial perspective. Finally, I present evidence for the current therapies prescribed for depressed elders, ranging from medications to group therapy.

Older criminals: a descriptive study of psychiatrically examined offenders in Sweden

OBJECTIVE

We retrospectively examined psychiatric diagnoses of older offenders referred by court for psychiatric assessment in Sweden, and compared them with younger offenders.

METHOD

In Sweden, structured court-ordered forensic psychiatric evaluations are undertaken by a forensic psychiatric team. Data on age, sex, citizenship, psychiatric diagnoses, offences, and legal insanity declarations were obtained for the years 1988-2000 (n = 7297).

RESULTS

There were 210 forensic psychiatric evaluations in those aged 60 and over. 7% had a diagnosis of dementia, 32% psychotic illness, 8% depressive or anxiety disorder, 15% substance abuse or dependence, and 20% personality disorder. Older offenders were significantly less likely to be diagnosed with schizophrenia or a personality disorder, and more likely to have dementia or an affective psychosis compared to younger ones. Logistic regression analyses suggested that of the studied factors, the ones most typical of older offenders were a diagnosis of dementia and being charged with a sexual offence.

CONCLUSION

There appear to be important differences in psychiatric morbidity between older offenders and younger ones who come into contact with forensic psychiatric services. This research may assist in the planning of forensic and therapeutic services for the increasing number of older adults passing through the criminal justice system.

How high is the prevalence of depression in old age?

Depressive symptoms are highly prevalent in late life - in Brazil and around the world. Some experts have argued that depression is less common in old age, quoting studies that show a lower prevalence of major depression in late life. Results from cross-age studies have been remarkably inconsistent, both regarding which age-group has the peak rate and regarding actual rates. A majority of surveys of the prevalence of depressive conditions in old age (not just major depression), warranting clinical interventions, report it to be over 10%. Physical ill-health is the most significant associated factor, but it may distract doctors from recognising depression. Clinical interventions for late life depression are worthwhile. It is recommended that funding be allocated to training in assessment and management, environmental initiatives to counter feelings of helplessness and lowered self-esteem, and research.

Is depression more prevalent in old age?

OBJECTIVE

To examine the prevalence of depression in old age and to review cross-age studies that reported age-related differences in prevalence.

METHOD

Reports of studies that included data on the prevalence of depression in old age were reviewed, and conclusions from review articles were considered.

RESULTS

Findings have been inconsistent, but majority opinion holds that depression (especially 'subsyndromal') is common in old age. There may be two peaks in the prevalence rate of major depression, one in late old age and the other in middle age or earlier.

CONCLUSIONS

The allocation of health care resources should not be determined by survey findings concerning the prevalence of major depression and dysthymia.

Depressive disorder as a predictor of physical disability in old age

OBJECTIVES

To determine whether the occurrence of depression predicts physical disability in older people.

DESIGN

A longitudinal epidemiological study with a follow-up of 5 years.

SETTING

A comparison between depressed and nondepressed participants.

PARTICIPANTS

The series consisted of the persons who participated in the longitudinal epidemiological study on depression in old age performed in Ahtari, Finland. The first round of interviews and examinations was performed in 1984/1985 and the second round in 1989/1990. The study series (N = 786) was composed of persons functionally independent in activities of daily living (ADLs) during the first round and alive and participating in both rounds.

MEASUREMENTS

Depression was determined according to DSM-III criteria. Physical functional abilities were measured with self-assessments of ability to manage ADLs.

RESULTS

In bivariate analyses, depression at the baseline did not predict lowering of functional abilities during follow-up, but the occurrence of depression with a long-term or relapsing course during follow-up and the onset of depression during follow-up in persons not depressed at the baseline predicted lowering of functional abilities during follow-up. The logistic regression analyses showed the presence of the following variables measured during the first round--older age, low basic education, poor self-perceived health, and occurrence of a physical disease--and the onset of the following diseases during follow-up--any physical disease, neurological disease, cerebrovascular disease, or depressive symptoms (in persons nondepressed at the baseline)--predicted lowered functional abilities after a follow-up of 5 years.

CONCLUSION

Depression that developed during the follow-up in previously nondepressed persons was associated with an increased risk for lowering of functional abilities, even when controlling for age, sociodemographic factors, physical diseases, and baseline disabilities. Depressed older people are at high risk for physical disability, and an individually planned program to maintain their functional abilities by training in ADLs and instrumental activities of daily living (IADLs) and physical exercise should be included in their treatment.

Conventional and new antidepressant drugs in the elderly

Depression in the elderly is nowadays a predominant health care problem, mainly due to the progressive aging of the population. It results from psychosocial stress, polypathology, as well as some biochemical changes which occur in the aged brain and can lead to cognitive impairments, increased symptoms from medical illness, higher utilization of health care services and increased rates of suicide and nonsuicide mortality. Therefore, it is very important to make an early diagnosis and a suitable pharmacological treatment, not only for resolving the acute episode, but also for preventing relapse and enhancing the quality of life. Age-related changes in pharmacokinetics and in pharmacodynamics have to be kept into account before prescribing an antidepressant therapy in an old patient. In this paper some of the most important and tolerated drugs in the elderly are reviewed. Tricyclic antidepressants have to be used carefully for their important side effects. Nortriptyline, amytriptiline, clomipramine and desipramine as well, seem to be the best tolerated tricyclics in old people. Second generation antidepressants are preferred for the elderly and those patients with heart disease as they have milder side effects and are less toxic in overdose and include the so called atypicals, such as selective serotonin reuptake inhibitors, serotonin noradrenalene reuptake inhibitors and noradrenaline reuptake inhibitors. Monoamine oxidase (MAO) inhibitors are useful drugs in resistant forms of depression in which the above mentioned drugs have no efficacy; the last generation drugs (reversible MAO inhibitors), such as meclobemide, seem to be very successful. Mood stabilizing drugs are widely used for preventing recurrences of depression and for preventing and treating bipolar illness. They include lithium, which is sometimes used especially to prevent recurrence of depression, even if its use is limited in old patients for its side effects, the anticonvulsants carbamazepine and valproic acid. Putative last generation mood stabilizing drugs include the dihydropyridine L-type calcium channel blockers and the anticonvulsants phenytoin, lamotrigine, gabapentin and topiramate, which have unique mechanisms of action and also merit further systematic study. Psychotherapy is often used as an adjunct to pharmacotherapy, while electroconvulsant therapy is used only in the elderly patients with severe depression, high risk of suicide or drug resistant forms.

Changes in intensity of physical exercise as predictors of depressive symptoms among older adults: an eight-year follow-up

BACKGROUND

Epidemiological research suggests that regular physical activity may be associated with reduced depressive symptoms. The present study examines the predictive value of physical exercise in relation to depressive symptoms among samples of adults aged 65+ during an 8-year period.

METHODS

The subjects (N = 663) who participated both at the baseline (1988) and the follow-up (1996) interviews were selected for the analyses. The dependent variable depressive symptoms was assessed by the Finnish modified version of Beck's 13-item depression scale. The independent variable was the intensity of physical exercise.

RESULTS

The intensity of physical exercise decreased among the older men and women. Those who had reduced their intensity of physical exercise during the 8 years reported more depressive symptoms at the follow-up than those who had remained active or increased their physical activity. Depressive symptoms were predicted by the intensity of baseline physical exercise, earlier depressive symptoms, older age, gender, having three or more chronic somatic conditions, and difficulties in performing ADL activities.

CONCLUSIONS

Age-related decrease in the intensity of physical exercise increases the risk of depressive symptoms among older adults. This calls for effective measures in maintaining and supporting an adequate level of physical exercise among the aging population.

The quality of life in Parkinson's disease

The objective of this study was to examine the quality of life in patients with Parkinson's disease (PD) in a community-based sample (n = 228 patients) using a Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) as a measure. Associations to the variables age, age at onset, duration, clinical stage (Hoehn and Yahr), depression (Zung), and dementia (MMSE) were studied. Women scored significantly lower on five of the eight dimensions of SF-36. Depression, as measured in this study, was more common among parkinsonian women than men. Depression was the factor that was associated most significantly with the experienced quality of life, according to SF-36. With physical functioning, only the clinical stage had a more significant association than depression. To improve the quality of life in patients with PD, it is necessary to make every effort to recognize and relieve the depression of patients with PD.

Oral health of patients scheduled for elective abdominal aortic correction with prosthesis

OBJECTIVE

to evaluate the frequency of potential oral foci of infection in patients scheduled for elective abdominal aortic surgery.

DESIGN

prospective clinical study.

MATERIALS

oral health and dentures of 50 patients (33 males and 17 females, mean age 65 years) were examined before aortic surgery.

CHIEF OUTCOME MEASURES

radiographic and clinical examination with special emphasis on identifying acute and chronic oral and ontogenic conditions which may contribute to aortic prosthesis infection.

RESULTS

eighty-two per cent of the patients had some oral infection foci. The mean number of remaining teeth in the cohort was 9.3, and 21% of these were potential infectious foci (62% in the patients). Twenty-six per cent of the patients suffered from oral Candida infection. Seventy-four per cent of the patients had total or partial dentures, 45% of which were ill-fitting and needed repair.

CONCLUSIONS

oral infectious foci occur frequently in patients needing aortic surgery. Untreated foci may contribute to aortic prosthesis infection. Preoperative oral evaluation and elimination of intraoral infection is recommended for patients scheduled for abdominal aortic repair.

Factors predicting the relapse of depression in old age

BACKGROUND

Studies in mixed-aged populations show differences between the predictors of a relapse and those of a long-term course of depression, supporting the hypothesis about similar differences among the aged.

AIM

The aim was to identify the factors predicting or related to a relapse of depression among the Finnish elderly having recovered from depression during treatment.

MATERIAL AND METHODS

The population consisted of 70 depressed (DSM-III criteria) elderly (60 yr-) Finns having recovered from depression during treatment as determined 15 months after baseline. By the 4-year follow-up after the recovery, 20 patients had relapsed and 50 persons were non-depressed.

RESULTS

The logistic regression model showed major depression and psychomotor retardation to be independent predictors. Relapses were not related to stressors in life or physical illnesses occurring during the follow-up.

CONCLUSIONS

Major depressive elderly patients have a high risk for relapses without the occurrence of the stressors or physical illnesses. In clinical practice, major depressive elderly patients should be followed up in order to detect and treat potential relapses as early as possible. Cooperation between psychiatrists and general practitioners is needed in the follow-up. Theoretically, the results suggest the assumption of a biochemical aetiology of major depression.

A path analysis model of self-rated health among older people

The aim of this study was to examine the structure of self-rated health among 75-year-old men and women. The study was part of the Evergreen project, comprising all the 75-year-old residents (N = 382) of Jyväskylä, in central Finland, in 1989. The data were collected by interviews, questionnaires and laboratory examinations, focusing on different domains of health and functional capacity. Of the target group, 91.6% (119 men and 231 women) participated in the interview, and 77.2% (104 men and 191 women) took part in the clinical and laboratory examinations. Path analysis models (LISREL 8) were used to examine the structure of self-rated health. About half the participants self-rated their health as good or unusually good. In both genders, a smaller number of difficulties in performing the physical activities of daily living (PADL), fewer chronic diseases, and better maximal working capacity were associated with better self-rated health. In addition, among the women a smaller number of depressive symptoms, and among the men better cognitive capacity had a positive effect on self-rated health. Physical activity and muscle strength had a positive indirect effect on self-rated health among both men and women. The explanatory power of the path analysis model for self-rated health was 44% for the men, and 42% for the women. The ability to perform the physical activities of daily living independently is an important associate of good self-rated health among older people. The path analysis models suggest that the factors underlying the physical activities of daily living also directly modify self-ratings of health among the elderly. The models of self-rated health for the men and the women were not exactly alike.

Marital and family relations and depression in married elderly Finns

BACKGROUND

The aim was to describe the relationships between poor marital and family relations and depression, and the predictive value of these factors for the subsequent occurrence of depression.

METHODS

The population for the cross-sectional study consisted of the married elderly (N = 498) living in Ahtäri, Finland, in 1989. The series of the longitudinal study was composed of married persons nondepressed in the epidemiological study in 1984-1985, and followed up until 1989-1990 (N = 347).

RESULTS

In men, impaired functional abilities (OR 5.0) and poor family relations (OR 2.9), and in women, impaired functional abilities (OR 3.9), family violence (OR 4.2), age 70 years or over (OR 3.0) and a loss of father in childhood or youth (OR 2.5) were independently related to depression. Poor marital relations tended to be related to depression in both men (OR 2.1) and women (OR 2.2). In both sexes, poor self-appreciation (OR men 3.9; women 7.1) and age 70 years or over (OR men 2.9; women 4.2), and in women, a loss of father in childhood or youth (OR 4.5) were independent predictors of subsequent depression.

CONCLUSIONS

The poor marital or family relations experienced by many depressed elderly persons are usually consequences rather than predictors of depression. Family violence may be a consequence of depression or even a risk factor for depression.

CLINICAL IMPLICATIONS

Problems in spouse pairs and families should be inquired and solved when treating depressed elderly persons.

LIMITATIONS OF THE STUDY

Due to the unknown validity of the measure concerning marital relations, the results are suggestive.