Prevalence and correlates of depression in a population of nonagenarians

The global prevalence of major depressive disorder (MDD) among the elderly: A systematic review and meta-analysis

BACKGROUND

Major depressive disorder is characterized by a depressed mood or feeling of sadness, loss of interest or pleasure in everyday activities. Depressed individuals have a cognitive impairment, low self-esteem, difficulty making decisions, feeling helpless and hopeless. The factors that have been associated with depression include the lack of social support, living in rural areas, suffering from chronic diseases, smoking, and alcohol abuse. This study aimed to investigate the global prevalence of major depressive disorder in the elderly.

METHOD

The electronic database such as Web of Science (WoS), Scopus, SID, PubMed, Google Scholar, Mag Iran, and IranDoc were systematically searched for studies reporting the prevalence of major depressive disorderin the elderly published up to March 2021. Meta-analysis was performed using Comprehensive Meta-Analysis (CMA) software. Heterogeneity between the studies was evaluated using the I² index. Begg and Mazumdar rank correlation test was used to assess publication bias.

RESULT

A total of 20 studies involving 18953 participants were included in this study. The global prevalence of major depression in the elderly was 13.3 % (95 % CI: 8.4-20.3 %). In the subgroup analysis, the prevalence of major depression in elderly women was 11.9 % (95 % CI: 7.6-18.6) and men 9.7 % (95 % CI: 5.2-17.3). No comparison was made between the two sexes, but based on the confidence intervals and large overlap, the two groups are not statistically different. Among continents, Australia had the highest prevalence of major depression in the elderly at 20.1 % (CI: 14.5-27.2 %). This was followed by Europe at 12.9 % (95 % CI: 5.1-28.9 %).

CONCLUSION

Major depressive disorder has a growing trend in the elderly population of the world. The prevalence of major depression in the elderly depends on various clinical and demographic factors such as age and gender. Therefore, mental health and the quality of life (QoL) of the elderly are important. The present study emphasizes the importance of social support in mental health that can reduce depression in the elderly.

The prevalence and predictors of anxiety and depression in near-centenarians and centenarians: a systematic review

BACKGROUND

Current research on the psychological health of near-centenarians (95-99 years old) and centenarians remains limited. Existing studies have mainly characterized their physical, cognitive, and social health. Results on the anxiety and depression of near-centenarians and centenarians (more than 95 years old) have been mixed with some studies, finding higher rates of anxiety and depression among those older than 95 years and others reporting no difference in rates compared with younger age groups. This study aims to synthesize the existing literature on the prevalence and predictors of anxiety and depression in near-centenarians and centenarians.

METHOD

A systematic review was conducted using Ovid Medline, Embase, PsycINFO, CINAHL, SCOPUS, and the Cochrane database. Common and conflicting findings among the literature were examined.

RESULTS

Thirty-eight studies met the inclusion criteria. Six studies examined the prevalence and predictors of anxiety, and 37 studies investigated the prevalence and predictors of depression. Five studies examined both anxiety and depression in the same sample. Prevalence data on anxiety and depression varied significantly, as did comparisons with rates in younger populations. Findings on predictors of anxiety and depression were contradictory.

CONCLUSION

There is a large degree of heterogeneity among studies of centenarians' psychological status. Findings conflict on the prevalence and predictors of anxiety and depression and rates compared with younger age groups. Variation in findings may result from the different inclusion criteria, sampling methods, and measurement tools. Better harmonization of centenarian study methodologies may improve consistency of findings to aid in developing clinical interventions.

The psychological health of 207 near-centenarians (95-99) and centenarians from the Sydney Centenarian Study

OBJECTIVE

While near-centenarians (95-99) and centenarians are the fastest growing sectors of the population in many countries, few studies have investigated their psychological health. We aimed to compare levels of psychological distress and life satisfaction in individuals aged 95 or above (95+) with younger age groups and identify the factors associated with psychological distress and life satisfaction in near-centenarians and centenarians.

METHODS

We assessed the physical, cognitive, social and psychological health of 207 participants aged 95+ in the Sydney Centenarian Study. Psychological distress and life satisfaction were rated on the Kessler Psychological Distress Scale (K10) and Satisfaction with Life Scale, respectively. Cross-sectional univariate comparisons were performed with participants aged 70-90 years from the Sydney Memory and Ageing Study. Factors associated with psychological distress and life satisfaction among Sydney Centenarian Study participants were examined using multiple regression analyses.

RESULTS

In Sydney Centenarian Study and Memory and Ageing Study, mean K10 scores were 15.3 (±5.9) and 13.4 (±3.6), and clinical levels of psychological distress (K10 ⩾ 20) were 19% and 7%, respectively. Sydney Centenarian Study participants demonstrated significantly higher levels and rates of psychological distress (t = 3.869, p < 0.001; χ² = 27.331, p < 0.001). In Sydney Centenarian Study, more psychotropic medications and having fewer relatives and friends were associated with higher psychological distress. Sydney Centenarian Study participants reported significantly higher levels of life satisfaction than Memory and Ageing Study participants, mean scores 6.0 (±1.5) and 5.6 (±1.3); t = 5.835, p < 0.001. Lower Mini-Mental State Examination scores and having fewer relatives and friends were associated with lower life satisfaction in Sydney Centenarian Study.

CONCLUSION

Despite showing higher levels of psychological distress in the prior 4 weeks than younger age groups, near-centenarians and centenarians remained highly satisfied with their overall lives. The identification of risk and protective factors for psychological distress and life satisfaction provides opportunities for interventions to maintain good psychological health in this vulnerable population.

The Gender Difference in Depression: Are Elderly Women at Greater Risk for Depression Than Elderly Men?

Numerous epidemiological reports have found that adolescent, young adult, and middle-aged adult girls and women are more likely to be diagnosed with unipolar depression and report greater symptoms of depression when compared to boys and men of similar ages. What is less well-known is whether this gender difference persists into late life. This literature review examines whether the well-known gender difference in unipolar depression continues into old age, and, if it does, whether the variables that are known to contribute to the gender difference in unipolar depression from adolescence through adulthood continue to contribute to the gender difference in the elderly, and/or whether there are new variables that arise in old age and contribute to the gender difference in the elderly. In this review of 85 empirical studies from every continent except for Antarctica, we find substantial support for the gender difference in depression in individuals who are 60 and older. More research is necessary to determine which factors are the strongest predictors of the gender difference in depression in late life, and particularly whether the factors that seem to be responsible for the gender difference in depression in earlier life stages continue to predict the gender difference in the elderly, and/or whether new factors come into play in late life. Longitudinal research, meta-analyses, and model-based investigations of predictors of the gender difference in depression are needed to provide insights into how and why the gender difference in depression persists in older age.

Phytopharmaceutical treatment of anxiety, depression, and dementia in the elderly: evidence from randomized, controlled clinical trials

Based on subgroup analyses of randomized, controlled clinical trials, we review the efficacy of three phytopharmaceutical drugs, respectively of the corresponding active substances silexan® (WS® 1265, lavender oil) in anxiety disorders, WS® 5570 (Hypericum extract) in major depression, and EGb 761® (Ginkgo biloba extract) in Alzheimer, vascular, or mixed type dementia, in elderly patients aged ≥ 60 years. Four trials were eligible in each indication. Meta-analyses and analyses based on pooled raw data showed that the three drugs were significantly superior to placebo in the elderly subset, and that their treatment effects reflected in the main outcome measures (Hamilton Anxiety scale, Hamilton Depression scale, Neuropsychiatric Inventory) were comparable with those observed in the original trials without age restrictions. The results confirm the efficacy of the three herbal active substances in elderly patients of ≥ 60 years of age. In anxiety, depression, and dementia, they thus represent efficacious and well-tolerated alternatives to synthetic drugs.

Prevalence of psychiatric disorders in U.S. older adults: findings from a nationally representative survey

Data on the prevalence of psychiatric disorders in late life are lacking. The present study addresses this gap in the literature by examining the prevalence of the broadest range of psychiatric disorders in late life to date; comparing prevalences across older adult age groups using the largest sample of adults aged 85+; and exploring gender differences in the prevalence of psychiatric disorders in late life. Using data from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions, we examined the prevalence of past-year mood, anxiety, and substance use disorders, and lifetime personality disorders in a nationally representative sample of 12,312 U.S. older adults. We stratified our analyses by gender and by older age groups: young-old (ages 55-64), middle-old (ages 65-74), old-old (ages 75-84), and oldest-old (ages 85+). The proportion of older adults who experienced any past-year anxiety disorder was 11.4%, while the prevalence of any past-year mood disorder was 6.8%. A total of 3.8% of older adults met criteria for any past-year substance use disorder, and 14.5% of older adults had one or more personality disorder. We observed a general pattern of decreasing rates of psychiatric disorders with increasing age. Women experienced higher rates of mood and anxiety disorders, while men had higher rates of substance use disorders and any personality disorder. Gender differences in rates of most psychiatric disorders decreased with increasing age. These data indicate that psychiatric disorders are prevalent among U.S. older adults, and support the importance of prevention, diagnosis, and treatment of psychiatric disorders in this population.

Psychotropic prescribing in the oldest old attending a geriatric psychiatry service: a retrospective, cross-sectional study

OBJECTIVE

More people are living beyond their 90s, yet this group has not been much studied. This study aimed to describe a sample of non-agenarians and centerians attending an old age psychiatry service with a focus on pharmacotherapy.

METHODS

Retrospective, cross-sectional survey of patients aged >90 in contact with the Department of Old Age Psychiatry in a university hospital over a 1-year period. Results were compared with the Beers, the Canadian and Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria.

RESULTS

A total of 65 nonagenarians or centerians were identified (mean age 93, 82% female). The majority (65%) resided in a nursing home; dementia was the most common diagnosis (77%), followed by depression (29%). The most commonly prescribed psychotropics were antidepressants (58%), followed by antipsychotics (45%), hypnotics (42%), anti-dementia agents (31%) and anxiolytics (26%). Overall, patients were on a mean of 2.1 (S.D. 1.3, range 0-5) psychotropics and 4.99 (S.D. 2.7, range 0-11) non-psychotropics. Mean Mini Mental State Examination (MMSE) score was 15 (S.D. 8.1). Increasing anticholinergic burden was negatively associated with MMSE scores (B = -1.72, p = 0.013). Residing in a nursing home was associated with a higher rate of antidepressant [OR 5.71 (95% CI 1.9-17.4)], anxiolytic [OR 13.5 (95% CI 1.7-110.4)] and antipsychotic [OR 3.4 (95% CI 1.1-10.4)] use. Potentially inappropriate prescribing included long-term benzodiazepine use (26%) and long-term antipsychotic use (25%).

CONCLUSIONS

Our sample had a high psychiatric morbidity burden with high levels of psychotropic use. Ongoing review and audit of psychotropic use in elderly patients can identify potentially inappropriate prescribing in a group vulnerable to high levels of polypharmacy and extended psychotropic use.

[Screening for depression in an elderly population living at home. Interest of the Mini-Geriatric Depression Scale]

BACKGROUND

Depression is the most usual mental disorder in the elderly, but underdiagnosed and undertreated. Its prevalence is variable. Symptoms of depression present in the elderly can be masked and difficult to recognize. The purpose of this study was to examine prevalence and risk factors for depression in elderly living in their home.

METHODS

A cross-sectional study of randomly selected homes in randomly selected geographical islets was carried out Monastir City (Tunisia). Questionnaire-based interviews were conducted among the elderly aged more than 65 years living in their home. Depression symptoms were assessed using a Mini-Geriatric Depression Scale. The relationship between the risk of depression and sociodemographic and health-related variables was studied using logistic regression.

RESULTS

Out of 598 (female 66 %, mean (SD) age 72.3 (7.4) years) elderly persons interviewed, 136 (22.7 %) were screened to have a Mini-Geriatric Depression Scale more than or equal to 1. Multiple logistic regression analysis revealed that the following were significant (P<0.01) independent predictors of risk of depression: female sex (OR=2.36 [95 % CI=1.43-3.94]), having a low level of education (OR=4.02 [95 % CI=1.38-11.65]), disability (OR=3.50 [95 % CI=1.94-6.46]), a history of stroke (OR=2.90 [95 % CI=1.20-7.72]) and the use of hypnotic medications (OR=2.47 [95 % CI=1.38-4.42]).

CONCLUSION

This study suggests that the risk of depression is a common psychiatric disorder in elderly living in their home, and underlines the usefulness of the Mini-Geriatric Depression Scale to detect the risk of depression in the elderly. This clinical approach should be encouraged in all medical practices to improve the prognosis of depression in the elderly.

Deriving prevalence estimates of depressive symptoms throughout middle and old age in those living in the community

BACKGROUND

There is considerable debate about the prevalence of depression in old age. Epidemiological surveys and clinical studies indicate mixed evidence for the association between depression and increasing age. We examined the prevalence of probable depression in the middle aged to the oldest old in a project designed specifically to investigate the aging process.

METHODS

Community-living participants were drawn from several Australian longitudinal studies of aging that contributed to the Dynamic Analyses to Optimise Ageing (DYNOPTA) project. Different depression scales from the contributing studies were harmonized to create a binary variable that reflected "probable depression" based on existing cut-points for each harmonized scale. Weighted prevalence was benchmarked to the Australian population which could be compared with findings from the 1997 and 2007 National Surveys of Mental Health and Well-Being (NSMHWB).

RESULTS

In the DYNOPTA project, females were more likely to report probable depression. This was consistent across age levels. Both NSMHWB surveys and DYNOPTA did not report a decline in the likelihood of reporting probable depression for the oldest old in comparison with mid-life.

CONCLUSIONS

Inconsistency in the reports of late-life depression prevalence in previous epidemiological studies may be explained by either the exclusion and/or limited sampling of the oldest old. DYNOPTA addresses these limitations and the results indicated no change in the likelihood of reporting depression with increasing age. Further research should extend these findings to examine within-person change in a longitudinal context and control for health covariates.

Psychiatric disorders in the elderly

Recent research has shown that depression, anxiety disorders, and psychosis are more common than previously supposed in elderly populations without dementia. It is unclear whether the frequency of these disorders increases or decreases with age. Clinical expression of psychiatric disorders in old age may be different from that seen in younger age groups, with less and often milder symptoms. Concurrently, comorbidity between different psychiatric disorders is immense, as well as comorbidity with somatic disorders. Cognitive function is often decreased in people with depression, anxiety disorders, and psychosis, but whether these disorders are risk factors for dementia is unclear. Psychiatric disorders in the elderly are often related to cerebral neurodegeneration and cerebrovascular disease, although psychosocial risk factors are also important. Psychiatric disorders, common among the elderly, have consequences that include social deprivation, poor quality of life, cognitive decline, disability, increased risk for somatic disorders, suicide, and increased nonsuicidal mortality.

One-month prevalence of mental disorders in a population sample of 95-year olds

OBJECTIVE

To determine the 1-month prevalence of mental disorders among 95-year olds.

DESIGN

Cross-sectional population sample of 95-year olds.

SETTING

: All 95-year olds born in the period 1901-1903 living in Gothenburg, Sweden, were invited. Elderly living in both community settings and nursing homes were included.

PARTICIPANTS

In total, 338 95-year olds (response rate: 65%) were examined (263 women, 75 men).

MEASUREMENTS

All participants were examined by psychiatrists using the Comprehensive Psychopathological Rating Scale and cognitive tests. Mental disorders were classified according to Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised criteria.

RESULTS

Two-third of all 95-year olds had a mental disorder. In the total sample of 95-year olds, the 1-month prevalence was 52% for dementia, 8% for depression, 4% for anxiety, and 3% for psychotic disorders. Almost one-third (29%) of the nondemented 95-year olds fulfilled criteria for a psychiatric disorder: 17% had depression, 9% anxiety, and 7% psychotic disorder.

CONCLUSIONS

The combined prevalence of mental disorders was high among 95-year olds, even after excluding dementia. These findings emphasize the importance of research, care, and detection of psychiatric problems in this age group.

Depressive symptoms impair everyday problem-solving ability through cognitive abilities in late life

BACKGROUND

The association between depression and functional disability in late life remains unclear. This study aimed to explore the relationship between depressive symptoms and daily functioning through the mediation of cognitive abilities, measured by memory, reasoning, and speed of processing.

METHODS

The authors recruited 2,832 older adults (mean age = 73.6 years, standard deviation = 5.9) participating in the Advanced Cognitive Training for Independent and Vital Elderly Study. Structural equation modeling was applied to illustrate the relationship between depressive symptoms and everyday problem-solving ability through the mediation of cognitive abilities.

RESULTS

Depressive symptoms were associated with impaired everyday problem-solving ability directly and indirectly mediated through learning and memory, and reasoning. Although depressive symptoms were associated with speed of processing, speed of processing was not significantly related to everyday problem-solving ability.

CONCLUSIONS

This study conceptualizes the possible relationships between depressive symptoms and daily functioning with mediation of cognitive abilities and provides a feasible model for the prevention of functional impairment related to geriatric depressive symptoms.

Psychiatric services for the "old" old

BACKGROUND

Few studies have specifically examined mental health service delivery to persons aged over 84 years, often described as the "old" old. Our aim was to compare mental health service provision in Australia to persons aged 85 years and over with the "young" old and other age groups. We hypothesized that the "old" old would differ from the "young" old (65-84 years) by diagnostic category, rates of specialist psychiatric hospital admission, and use of Medicare funded psychiatric consultations in the community.

METHODS

Mental health service delivery data for 2001-02 to 2005-06 was obtained from Medicare Australia on consultant psychiatrist office-based, home visit and private hospital services subsidized by the national healthcare program and the National Hospital Morbidity database for separations (admitted episodes of patient care) from all public and most private hospitals in Australia on measures of age, gender, psychiatric diagnosis, location and type of psychiatric care.

RESULTS

Use of specialist psychiatric services in the community per annum per 1000 persons declined with age in men and women from 137.28 and 191.87 respectively in those aged 20-64 years to 11.84 and 14.76 respectively in those over 84 years. However, men and women over 84 years received psychiatric home visits at 377% and 472% respectively of the rates of persons under 65. The annual hospital separation rate per 1000 persons for specialist psychiatric care was lowest in those aged over 84 (3.98) but for inpatient non-specialized psychiatric care was highest in those over 84 (21.20). Depression was the most common diagnosis in specialized psychiatric hospitalization in those aged over 84 while organic disorders predominated in non-specialized care in each age group over 64 years with the highest rates in those aged over 84.

CONCLUSION

Mental health service delivery to persons aged over 84 is distinctly different to that provided to other aged groups being largely provided in non-specialist hospital and residential settings.

Depressive symptoms in the very old living alone: prevalence, incidence and risk factors

BACKGROUND

Living alone is one of many risk factors associated with depression. This project is nested within the ENABLE-AGE project designed to explore the relationship between housing environment and health in the very old living alone in their own homes.

AIM

Our aim is to describe the prevalence, incidence and associated risk factors of clinically significant depressive symptoms in this population with particular emphasis on the role of the home environment.

METHOD

We conducted a one year follow up of 376 subjects aged between 80 and 90 years old. Data collected included variables concerned with housing, social circumstances, physical health and psychological well being.

RESULTS

A prevalence rate of 21% and an annual incidence of 12.4% (Geriatric Depression Score of five or more) were found. Risk factors associated with prevalence depression include not living close to friends and family ((OR 2.540, CI; 1.442, 4.466), poor satisfaction with living accommodation (OR; 0.840, CI; 0.735, 0.961) and poor satisfaction with finances (OR; 0.841, CI; 0.735, 0.961). Subsequent development of clinically significant depressive symptoms was associated with base line increased scores in depression (OR; 1.68, CI; 1.206, 2.341).

CONCLUSIONS

These results are consistent with findings in the general population of similar age with the exception of considerably higher prevalence and incidence rates. However, we were unable to demonstrate that housing related variables were significant risk factors in terms of incidence cases.

CLINICAL IMPLICATIONS

Older people living alone are particularly vulnerable to depression and may benefit from targeted screening and development of appropriate care pathways.

Multi-target strategies for the improved treatment of depressive states: Conceptual foundations and neuronal substrates, drug discovery and therapeutic application

Major depression is a debilitating and recurrent disorder with a substantial lifetime risk and a high social cost. Depressed patients generally display co-morbid symptoms, and depression frequently accompanies other serious disorders. Currently available drugs display limited efficacy and a pronounced delay to onset of action, and all provoke distressing side effects. Cloning of the human genome has fuelled expectations that symptomatic treatment may soon become more rapid and effective, and that depressive states may ultimately be "prevented" or "cured". In pursuing these objectives, in particular for genome-derived, non-monoaminergic targets, "specificity" of drug actions is often emphasized. That is, priority is afforded to agents that interact exclusively with a single site hypothesized as critically involved in the pathogenesis and/or control of depression. Certain highly selective drugs may prove effective, and they remain indispensable in the experimental (and clinical) evaluation of the significance of novel mechanisms. However, by analogy to other multifactorial disorders, "multi-target" agents may be better adapted to the improved treatment of depressive states. Support for this contention is garnered from a broad palette of observations, ranging from mechanisms of action of adjunctive drug combinations and electroconvulsive therapy to "network theory" analysis of the etiology and management of depressive states. The review also outlines opportunities to be exploited, and challenges to be addressed, in the discovery and characterization of drugs recognizing multiple targets. Finally, a diversity of multi-target strategies is proposed for the more efficacious and rapid control of core and co-morbid symptoms of depression, together with improved tolerance relative to currently available agents.

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.

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.

Major depression as a risk factor for early institutionalization of dementia patients living in the community

OBJECTIVE

Although depression is known to be frequently associated with dementia, it is nonetheless under-diagnosed and under-treated among this patient population. Its effect on outcome for dementia patients is thought to be substantial, because depression appears to induce higher than normal rates of disability as well as supplementary cognitive decline. The aim of this study was to measure the impact of major depression on the institutionalization rate of community-dwelling dementia patients.

DESIGN

Prospective cohort study.

SETTING

Paris, France.

PARTICIPANTS

Three-hundred forty-eight consecutive dementia outpatients of a geriatric clinic (mean age: 81 years, 69.8% women, 65.5% dementia of Alzheimer's type, mean baseline MMSE score: 20.5), followed between 1997 and 2002 (mean follow-up: 20.5 months).

RESULTS

Twenty-five percent of the patients met the criteria of major depression at baseline, and only 30.3% of these received antidepressant medication. Major depression at baseline was independently associated with nursing home admission within one year of the baseline assessment. Antidepressant medication tended to protect against this outcome, but not to a statistically significant extent.

CONCLUSIONS

Major depression at baseline is an independent risk factor for early institutionalization of dementia sufferers. Early institutionalization is defined in this study as nursing home placement within a year of diagnosis with dementia at our specialized outpatient center. The study highlights the need for better management of depression among dementia outpatients. Further investigation is needed to evaluate the protective effect of antidepressant medication (and/or non-pharmacological therapies) on the institutionalization rate.

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.

Prevalence, correlates and recognition of depression in the oldest old: the Leiden 85-plus study

BACKGROUND

Various studies support the notion that the clinical picture of depression in the oldest old differs from that in younger elderly. Moreover, withstanding the serious negative effects of depression on well being and functioning, the detection rate of depression in several medical settings is low.

METHODS

Prevalence of depression, correlates and the rate of recognition by general practitioners were assessed in an 85-year-old community-based population. The GDS-S was applied in 500 participants with a MMSE >18, from a representative sample of 599 community based 85-year-old subjects. Demographic data, daily functioning, health correlates, use of medication and recognition of depression were recorded in home visits and from the general practitioner and pharmacists registers.

RESULTS

The prevalence of depression, as measured with a GDS-S score of 5 points or more, was 15.4%, which is comparable to previous studies. No demographic factors were correlated with depression. Perceived health, loneliness, impaired mobility, cognitive decline and functional disability were major correlates of depression. From the participants who were seen by their general practitioner, 25% were recognised as depressed. Antidepressive pharmacotherapy was almost nonexistent.

LIMITATIONS

Formal diagnosis of depression was not available. The data were collected cross-sectionally.

CONCLUSIONS

Depression is highly prevalent in the oldest old and strongly associated with functional disability and cognitive impairment. It is important to enhance recognition of depression in community based oldest old as a first step to possible interventions.

Prevalence of DSM-IV psychiatric disorder in the French elderly population

BACKGROUND

France has high rates of psychotropic drug consumption and suicide in the elderly population, but it has not yet been possible to determine whether this is due to exceptionally high morbidity rates.

AIMS

To describe the first longitudinal population study of psychiatric disorder undertaken in France, and to estimate current and lifetime prevalences and age of onset of psychiatric disorder.

METHOD

A study group of 1873 non-institutionalised persons aged 65 years and over was randomly recruited from the Montpellier district electoral rolls. The Mini International Neuropsychiatric Interview was used to assess current and lifetime symptoms. Cases identified by the application of DSM-IV criteria were re-examined by a clinical panel.

RESULTS

Forty-six per cent of the study population had experienced a mental disorder in their lifetime, and 3.7% had made a suicide attempt. Lifetime prevalence of major depression was 26.5% and 30% for anxiety disorders. Current prevalence rates were 14.2% for anxiety disorders, 10.7% for phobia, 3% for major depression and 1.7% for psychosis.

CONCLUSIONS

Results show very high rates of lifetime but not current major depression. Rates of current phobia and suicidal ideation in the very elderly are also high compared with other studies. The rates reported are likely to be underestimates.

The impact of religious practice and religious coping on geriatric depression

OBJECTIVE

Both religiousness and social support have been shown to influence depression outcome, yet some researchers have theorized that religiousness largely reflects social support. We set out to determine the relationship of religiousness with depression outcome after considering clinical factors.

METHODS

Elderly patients (n=114) in the MHCRC for the Study of Depression in Late Life while undergoing treatment using a standardized algorithm were examined. Patients completed measures of public and religious practice, a modified version of Pargament's RCOPE to measure religious coping, and subjective and instrument social support measures. A geriatric psychiatrist completed the Montgomery-Asberg Depression Rating Scale (MADRS) at baseline and six months.

RESULTS

Both positive and negative religious coping were related to MADRS scores in treated individuals, and positive coping was related to MADRS six months later, independent of social support measures, demographic, and clinical measures (e.g. use of electro-convulsive therapy, number of depressed episodes). Public religious practice, but not private religious practice was independently related to MADRS scores at the time of completion of the religiousness measures. Religious coping was related to social support, but was independently related to depression outcome.

CONCLUSIONS

Clinicians caring for older depressives should consider inquiring about spirituality and religious coping as a way of improving depressive outcomes.

Women are more disabled in basic activities of daily living than men only in very advanced ages: a study on disability, morbidity, and mortality from the Kungsholmen Project

OBJECTIVE

We explored the effect of morbidity, mortality, and occurrence of new disability on gender differences in activities of daily living (ADL) functioning in different age groups in the elderly population.

METHODS

All 77+-year-old members of a community-based cohort were clinically examined by physicians, assessed by psychologists, and interviewed by nurses at baseline and after a 3-year interval. Diseases were diagnosed according to ICD-9 and the DSM-III-R criteria for dementia. The Katz index of ADL was used to measure basic functional status.

RESULTS

After adjustment for socio-demographic characteristics, the oldest women (90+ years) had higher disability prevalence and a tendency for higher long-term disability incidence. Women aged 85+ years also had higher morbidity prevalence. Mortality among disabled subjects was similar for both genders, whereas higher mortality was found in younger nondisabled men (77-84 years).

CONCLUSION

We conclude that gender differences in disability, morbidity, and mortality vary with age in the elderly population. Gender differences in morbidity and basic functional dependence were evident only in the oldest old. Based on current and previous findings, we speculate that more women may be at higher risk of developing severe disability than men in the advanced ages due to longer survival with slight disability earlier in adult life.

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.

Relationship between depressive symptomatology and the subcortical brain syndrome in dementia

OBJECTIVES

the aim of the present study was to elucidate a possible relationship between depressive symptomatology and regional brain symptomatology in demented patients.

METHODS

170 consecutive inpatients were studied. They suffered from Alzheimer's disease (103 patients), vascular dementia (48 patients), or frontotemporal dementia (19 patients). The patients underwent a neuropsychiatric investigation, which included assessments of (1) depression, and (2) regional brain symptomatology. Depressive symptomatology was assessed as presence of (a) depressed mood, and (b) anxiety. In the further statistical analysis, the presence of depressed mood and/or anxiety was also evaluated. The principle of the regional symptom analysis was the successive aggregation of observable symptom variables, leading to the final determination of four possible regional brain syndromes (frontal, subcortical, parietal and global), by way of the Stepwise comparative status analysis (STEP). The possible correlations between regional brain symptomatology and depressive symptomatology were analysed by means of (a) chi(2) statistics, and (b) a logistic regression analysis in which confounding factors were included (age, degree of dementia, duration).

RESULTS

the subcortical syndrome correlated with depressed mood (chi(2), p = 0.002; logistic regression, p = 0.002). A negative correlation was noted between the parietal syndrome and depressed mood (p = 0.010 and p = 0.013, respectively). No other significant correlations between presence of regional brain syndrome and presence of depressive symptomatology could be seen.

CONCLUSIONS

demented patients with a clinically established subcortical dysfunction appear to be more susceptible to depressive symptomatology. The results of this study also suggest that posterior brain dysfunction in dementia is not correlated with depressive symptomatology.

The influence of age on the female/male ratio of treated incidence rates in depression

BACKGROUND

Poor data exist on the influence of psychosocial variables on the female/male ratio of depression because of the small number of cases and the resulting limited numbers of variables available for investigation. For this investigation a large number of first admitted depressed patients (N = 2599) was available which offered the unique opportunity to calculate age specific sex ratios for different marital and employment status categories.

METHODS

Age and sex specific population based depression rates were calculated for first ever admissions for single year intervals. Moving averages with interpolated corrections for marginal values in the age distribution were employed.

RESULTS

For the total group the female/male ratio of depression showed an inverted U-shape over the life-cycle. This pattern was influenced by the group of married persons, which showed a sex-ratio of 3:1 between the age of 30-50, but ratios of around 1:1 at younger and older ages. For not married persons the female/male ratio was already around 2:1 at the age of 18 and rose to 2.5:1 in mid-life and declined to 1 at around 55. The almost parallel decline of depression rates in employed men and women resulted in a female/male ratio of about 2:1 from age 18 to age 50 and became 1 after the age of 60. The female/male ratio among the not employed was about 1, in mid-life it became negative.

CONCLUSIONS

Our analyses show that the gender-gap in first admitted depressed patients is age dependent and that psychosocial factors modify the sex ratio.

Bupropion SR in the naturalistic treatment of elderly patients with major depression

INTRODUCTION

Bupropion immediate release (IR) and bupropion sustained release (SR) are frequently used to treat geriatric depression, as they have few cardiovascular, gastrointestinal and sexual adverse effects. We sought to examine the efficacy and dosing patterns of bupropion in a naturalistic cohort of elderly subjects with major depression (MD).

METHODS

31 elderly ( > 60 years) patients with unipolar MD (DSM-IV) who were enrolled in Duke's Mental Health Clinical Research Center for the Study of Depression in Later Life were prescribed bupropion SR or IR, alone or in combination with other antidepressant agents, for 12 weeks. Montgomery-Asberg depression rating scale (MADRS) scores and clinical global impression (CGI) severity scores were used to define response.

RESULTS

74% (23/31) of the sample were responders (MADRS < 15) and 53% (16/30) achieved a partial (CGI = 2) or complete (CGI = 1) remission of MD at week 12. Among patients treated with bupropion SR monotherapy, the mean (range) maximal daily dose achieved was 240 mg (150-400 mg). Among those treated with bupropion IR, the mean (range) maximum daily dose achieved was 258 mg (150-450 mg). In subjects on monotherapy, 67% (10/15) of MD subjects were responders (MADRS < 15) and 50% (7/14) achieved full or partial remission. Response rates did not differ statistically among those with high and low medical comorbidity.

CONCLUSIONS

In this naturalistic 12-week study, geriatric MD patients with high and low medical comorbidity responded well to bupropion and bupropion SR. In elderly patients, four to eight week acute treatment periods may be insufficient. Our findings suggest that nearly 50% of elderly depressed subjects at a tertiary center may need combination therapy over the course of their illness. Controlled randomized studies to establish the long-term efficacy and optimal dose of the newer antidepressants in geriatric depression are urgently needed.

Functional status and self-rated health in 2,262 nonagenarians: the Danish 1905 Cohort Survey

OBJECTIVES

To describe the functional capacity and self-rated health of a large cohort of nonagenarians.

DESIGN

A cross-sectional survey of all Danes born in 1905 (92-93 years of age), carried out August to October 1998.

SETTING

Participants' homes.

PARTICIPANTS

Two thousand two hundred and sixty-two nonagenarians, corresponding to a participation rate of 63% (of these, 20% participated by proxy).

MEASUREMENTS

Activities of daily living (ADLs) and self-rated health were assessed by interview. Five items from Katz's ADLs (bathing, dressing, transfer, toileting, and eating) were used to construct a three-level five-item ADL scale (not disabled (no disabilities), moderately disabled (1-2 disabilities), severely disabled (3-5 disabilities)). From responses to a more extensive list of questions on ADLs (26 items), we identified scales of strength and agility by means of factor analysis. Furthermore, a 26-item ADL scale was made. Physical performance tests (chair stand, timed walk, lifting a 2.7 kg box, maximum grip-strength, and flexibility tests) were performed among nonproxy responders.

RESULTS

According to the five-item ADL scale, 50% of the men and 41% of the women were categorized as not disabled, while 19% and 22%, respectively, were categorized as severely disabled. The five-item ADL scale correlated highly with the 26-item ADL scale (r = 0.83). The ADL scales showed moderate-to-good correlation with each other (r = 0.74-0.83), and with the physical performance tests (r = 0.31-0.58). Only 3.7% of the women and 6.3% of the men walked (normal pace) with a speed of at least 1 meter per second, which is the minimum walking speed required to cross signaled intersections in Denmark. A total of 56% considered their health to be excellent or good. Of the participants, 74% were always or almost always satisfied with their lives, even though only 45% reported that they "felt well enough to do what they wanted." The analyses showed that no single ADL item seemed to be of particular importance for how the participants rated their health.

CONCLUSION

The Danish 1905 cohort survey is the largest and the only nationwide survey of a whole birth-cohort of nonagenarians. A total of 2,262 fairly nonselected nonagenarians participated. The level of both self-reported disability and functional limitations measured by physical performance tests among nonagenarians was high. Despite their lower mortality, women were more disabled than men and did not perform as well as men in the physical performance tests. Nevertheless, the majority of the participants considered their health to be good and were satisfied with their lives.

Depressive syndromes and functional disability in dementia

The goals of this study were to assess (1) the prevalence of major and minor depression in Alzheimer's disease (AD), ischemic vascular dementia (IVD), and mixed dementia (AD/IVD); (2) demographic and clinical variables that may be associated with depression; and (3) the relationship between depression severity and the level of functional impairment and cognitive decline. Demographic variables, depression diagnoses, Mini-Mental State Examination scores, and Blessed Roth Dementia Rating Scale scores were compared in patients with AD (N = 582), IVD (N = 48), and mixed dementia (N = 61) using analysis of variance and linear regression models. Data were collected using standardized rating instruments at the time of the patients' initial evaluations at the University dementia clinics. The results were that (1) depression was related to lower education, (2) major depression was more prevalent in IVD compared to probable AD, and (3) functional impairment was greater in patients with minor or major depression compared to patients without depression. Our data suggest that the level of functional disability in dementia may be related to severity of depression. Additional studies are needed to validate our results and examine the contribution of additional neurobiologic factors to the pathophysiology of depression in dementia.

The Danish 1905 cohort: a genetic-epidemiological nationwide survey

OBJECTIVES

The authors studied nonagenarians, a rapidly growing age group whose cognitive and physical abilities have yet to be investigated systematically.

METHODS

All Danes born in 1905 were invited to participate in a home-based 2-hour multidimensional interview, including cognitive and physical performance tests and collection of DNA, carried out by lay interviewers. Population-based registers were used to evaluate representativeness.

RESULTS

There were 2,262 participants. A total of 1,632 (72%) gave a DNA sample. Participants and nonparticipants were highly comparable with regard to marital status, institutionalization, and hospitalization patterns, but men and rural area residents were more likely to participate. Six months after the survey began, 7.2% of the participants and 11.8% of the nonparticipants had died.

DISCUSSION

Despite the known difficulties of conducting surveys among the extremely old, it was possible to conduct a nationwide survey, including collection of DNA, among more than 2,000 fairly nonselected nonagenarians using lay interviewers.

Morbidity and comorbidity in relation to functional status: a community-based study of the oldest old (90+ years)

OBJECTIVES

To describe health and functional status in the oldest old; to explore the relationships of morbidity and functional status; and to verify whether this relationship was modified by gender.

DESIGN AND SETTING

A community-based survey including all inhabitants aged > or = 90 living in central Stockholm, Sweden. All participants were clinically examined by physicians, cognitively assessed by psychologists, and interviewed by nurses. Diagnoses were made according to the International Classification of Diseases-Ninth Revision (ICD-9), the DSM-III-R criteria for dementia, and Katz index of activities of daily living.

PARTICIPANTS

Of the 698 subjects in the study population, 99 (14%) had died and 29 (4%) moved before examination. Of the remaining subjects, 502 (88.1%) were examined, and the refusal rate was 11.9%.

MEASUREMENTS

Age- and gender-specific prevalence figures, and age-, gender- and education-adjusted odds ratios (OR) were used.

RESULTS

Of 502 examined subjects, 19% had no disease and 73% were functionally independent. Dementia was the most prevalent disease among women (42.2%), and cardio- and cerebrovascular diseases were the most frequent among men (42.4%). Women had higher prevalences of dementia (adjusted OR = 2.1, 95% confidence interval (CI) 1.2-3.7) and fractures and musculoskeletal diseases (adjusted OR = 2.8, 95% CI 1.1-7.3), whereas men had a higher prevalence of malignancy (OR = 0.2, 95% CI 0.1-0.7). Women were more disabled than men independent of age, education, and number of diseases (adjusted OR = 2.2, 95% CI 1.1-4.3).

CONCLUSIONS

A great proportion of nonagenarians were functionally independent despite their advanced age. Further studies are needed to clarify the excess of disability among very old women.

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.

Gender differences in the recognition of depression in old age

OBJECTIVE

The study should answer the question of whether identical symptom presentations of depression in male and female patients leads to similar recognition rates in primary care.

METHOD

We performed a survey in primary care. Two written case vignettes were presented to 170 family physicians in a face-to-face interview which took place in their practices. The case vignettes described either a mildly depressed otherwise healthy old patient (case 1) or a severely depressed patient with somatic comorbidity (case 2). For each case different versions with regard to patients' gender were used: in case 1 only the gender of the patient varied; in case 2 both the gender and the anamnesis (stroke/hypothyroidism) varied. Afterwards the interviewers asked standardised open questions. The physicians were not aware of the mental health focus and the gender focus of the study.

RESULTS

The study is representative with a response rate of 77.6%. For primary diagnosis, the female versions were given the diagnosis of depression more often. There was a non-significant trend that female physicians considered depression more often.

CONCLUSION

The results show that gender-related experience and stereotypes on the physicians' side influence the diagnosis of (old age) depression in primary care. Further studies should elucidate the influence of the physicians' gender on the management of psychiatric disorders.

Depression symptoms in late life assessed using the EURO-D scale. Effect of age, gender and marital status in 14 European centres

BACKGROUND

Data from surveys involving 21,724 subjects aged > or = 65 years were analysed using a harmonised depression symptom scale, the EURO-D.

AIMS

To describe and compare the effects of age, gender and mental status on depressive symptoms across Europe.

METHOD

We tested for the effects of centre, age, gender and marital status on EURO-D score. Between-centre variance was partitioned according to centre characteristics: region, religion and survey instrument used.

RESULTS

EURO-D scores tended to increase with age, women scored higher than men, and widowed and separated subjects scored higher than others. The EURO-D scale could be reduced into two factors: affective suffering, responsible for the gender difference, and motivation, accounting for the positive association with age.

CONCLUSIONS

Large between-centre differences in depression symptoms were not explained by demography or by the depression measure used in the survey. Consistent, small effects of age, gender and marital status were observed across Europe. Depression may be overdiagnosed in older persons because of an increase in lack of motivation that may be affectively neutral, and is possibly related to cognitive decline.

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

OBJECTIVE

To analyze the differences between variables associated with depression and symptoms of depression in demented and nondemented persons.

DESIGN

A survey design was used.

SETTING/PARTICIPANTS

A total of 1101 older persons registered in a district of Stockholm, Sweden, participated in the study.

MEASUREMENTS

Subjects were given physical and psychiatric examinations by physicians, and informants interviews and medical records were assessed. Dementia was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) criteria and major depression according to DSM-IV. The variables studied were age, gender, martial status, institutionalization, Mini-Mental State Exam score, disability in daily life, physical disorders with symptoms affecting daily life, and a previous history of depression (early and late).

RESULTS

27.8% of the patients in the study sample were demented according to DSM-III-R. Major depression was diagnosed in 3.9% of the nondemented and in 11.8% of the demented subjects. Some of the depressive symptoms, such as lack of energy, thinking/concentration difficulties, loss of interest, and psychomotor disturbance, were found more commonly in demented than in nondemented persons. Increased disability was associated with major depression both in demented and nondemented persons.

CONCLUSION

In this study, the prevalence of depression was higher in demented than in nondemented persons. Among the factors that were studied, increased disability was associated with depression both in demented and nondemented persons. No differences were found regarding the other studied variables.

Incidence of dementia in a Munich community sample of the oldest old

In a two-wave community study a representative sample of 402 very old people (older than 85 years) was restudied 1 year later. Four instruments in the clinical examination were used for case identification: (a) the Geriatric Mental State Interview (GMS-A); (b) the Structured Interview for the Diagnosis of Dementia (SIDAM); (c) the Global Deterioration Scale (GDS); and (d) the Mini Mental State Examination (MMSE). The clinical examination was performed by the interviewing physician who made a diagnosis according to DMS-III-R. The focus of the present study is on the (true) incidence of dementia in a representative community sample. The establishment of incidence rates is particularly important for dementia because the prevalence of dementia is affected by the length of survival, which is reduced in dementia and with increasing age. The annual incidence rates per 1000 person years on the basis of the SIDAM DSM-III-R were 116.6 for all cases at risk, 113.6 for those aged 85-89 years, 112.5 for those aged 90-94 years and 235.7 for those aged 95 years and older at first assessment (t1). Incidence rates based on the other methods of assessment are reported. In order to obtain the most meaningful estimate of incidence rates a compound dementia diagnosis was defined. According to this the annual incidence rate per 1000 person years was 144.1 for all persons at risk. The incidence rate tended to be higher in the older-age cohorts: It was 126.2 for those aged 85-89 years, 193.1 for those aged 90-94 years and 295.5 for those aged 95 years and older. In comparison with the literature the incidence rates were high. The results are plausible when the very old age of the sample is taken into account.