Type 2 diabetes mellitus in people with severe mental illness: inequalities by ethnicity and age. Cross-sectional analysis of 588 408 records from the UK

AIMS

To investigate whether the association of severe mental illness with Type 2 diabetes varies by ethnicity and age.

METHODS

We conducted a cross-sectional analysis of data from an ethnically diverse sample of 588 408 individuals aged ≥18 years, registered to 98% of general practices (primary care) in London, UK. The outcome of interest was prevalent Type 2 diabetes.

RESULTS

Relative to people without severe mental illness, the relative risk of Type 2 diabetes in people with severe mental illness was greatest in the youngest age groups. In the white British group the relative risks were 9.99 (95% CI 5.34, 18.69) in those aged 18-34 years, 2.89 (95% CI 2.43, 3.45) in those aged 35-54 years and 1.16 (95% CI 1.04, 1.30) in those aged ≥55 years, with similar trends across all ethnic minority groups. Additional adjustment for anti-psychotic prescriptions only marginally attenuated the associations. Assessment of estimated prevalence of Type 2 diabetes in severe mental illness by ethnicity (absolute measures of effect) indicated that the association between severe mental illness and Type 2 diabetes was more marked in ethnic minorities than in the white British group with severe mental illness, especially for Indian, Pakistani and Bangladeshi individuals with severe mental illness.

CONCLUSIONS

The relative risk of Type 2 diabetes is elevated in younger populations. Most associations persisted despite adjustment for anti-psychotic prescriptions. Ethnic minority groups had a higher prevalence of Type 2 diabetes in the presence of severe mental illness. Future research and policy, particularly with respect to screening and clinical care for Type 2 diabetes in populations with severe mental illness, should take these findings into account.

Education for people with progressive neurological conditions can have negative effects: Evidence from a randomized controlled trial

Objectives: To test the effects of a home-based educational intervention in reducing the incidence and the risk of falls and pressure sores in adults with progressive neurological conditions.

Design: Randomized controlled trial with 12 months follow-up.

Setting: Participants’ homes in the City of Nottingham.

Participants: One hundred and fourteen people with progressive neurological conditions recruited from general practices in Nottingham, including 53 with Parkinson's disease and 45 with multiple sclerosis.

Interventions: In the education group (EG), baseline data were reviewed by an expert panel which advised on actions most likely to promote each individual's physical, social and psychological well-being. An occupational therapist (OT) then visited EG participants to provide education and information and to discuss a personalized 12-month health action plan. The comparison group (CoG) received standardized printed information delivered to their home.

Main measures: Numbers of participants reporting falls and skin sores at two-monthly phone calls during the follow-up period of 12 months.

Results: The EG reported significantly more falls during the follow-up period and at 12 months (adjusted odds ratio 2.83 (95% CI 1.07-7.47), p=0.036) and significantly more skin sores (adjusted odds ratio 12.74 (95% CI 1.14-142.6), p=0.039) than the CoG. There was no difference between CoG and EG in the Nottingham Extended Activities of Daily Living score, but EG patients showed a significant rise in this score over the study period of 1.62 (95% CI 0.69-2.55, p=0.002).

Conclusions: Our findings provide evidence that education for people with progressive neurological conditions can have negative effects.

Mild cognitive impairment diagnosed with the new DSM-5 criteria: prevalence and associations with non-cognitive psychopathology

OBJECTIVE

To contrast the prevalence of mild cognitive impairment (MCI) as diagnosed using DSM-5 criteria (DSM5-MCI) with MCI as diagnosed using Petersen's criteria (P-MCI) and to explore the association of both with non-cognitive psychopathological symptoms (NCPS).

METHOD

A two-phase epidemiological screening was implemented in a population-based sample of individuals aged 55+ (n = 4803). The Geriatric Mental State (GMS) was the main psychopathological instrument used, and AGECAT was used to make psychiatric diagnoses. Research psychiatrists diagnosed DSM5-MCI and P-MCI using operational criteria. Logistic regression models were then used to investigate the association of MCI with anxiety and depression and with NCPS.

RESULTS

Weighted prevalence of DSM5-MCI and P-MCI was, respectively, 3.72% and 7.93% for the aged 65+. NCPS were common in both MCI categories, but negative-type symptoms such as 'anergia' and 'observed slowness' were considerably more frequent among persons with DSM5-MCI. Anxiety and depression diagnostic categories were associated with both P-MCI and DSM5-MCI, but affective-type symptoms were mainly associated with P-MCI. Some negative-type symptoms were inversely associated with P-MCI, and no association was observed with DSM5-MCI.

CONCLUSION

The prevalence of DSM5-MCI was half that of P-MCI. Negative-type NCPS were more frequently and typically associated with DSM5-MCI.

Born into adversity: psychological distress in two birth cohorts of second-generation Irish children growing up in Britain

Background

Worldwide, the Irish diaspora experience health inequalities persisting across generations. The present study sought to establish the prevalence of psychological morbidity in the children of migrant parents from Ireland, and reasons for differences.

Methods

Data from two British birth cohorts were used for analysis. Each surveyed 17 000 babies born in one week in 1958 and 1970 and followed up through childhood. Validated scales assessed psychological health.

Results

Relative to the rest of the cohort, second-generation Irish children grew up in material hardship and showed greater psychological problems at ages 7, 11 (1958 cohort) and 16 (both cohorts). Adjusting for material adversity and maternal psychological distress markedly reduced differences. Relative to non-Irish parents, Irish-born parents were more likely to report chronic health problems (odds ratio [OR]: 1.29; 95% confidence interval [CI]: 1.08–1.54), and Irish-born mothers were more likely to be psychologically distressed (OR: 1.44; 95% CI: 1.13–1.84, when child was 10). Effect sizes diminished once material adversity was taken into account.

Conclusions

Second-generation Irish children experienced high levels of psychological morbidity, but this was accounted for through adverse material circumstances in childhood and psychological distress in parents. Public health initiatives focusing on settlement experiences may reduce health inequalities in migrant children.

Prescriptions with potentially hazardous/contraindicated drug combinations presented to community pharmacies

Focal points

Impairment, disability, social support and depression among older parents in rural Thailand

BACKGROUND

It is not known whether social support modifies the association between depression and impairment or disability in older people from developing countries in Asia.

METHOD

We used a Thai version of the EURO-D scale to measure depression in 1104 Thai rural community-dwelling parents aged 60 years. These were all those providing data on depression who were recruited as part of a study of older adults with at least one living child (biological, stepchild or adopted child). Logistic regression modelling was used to determine: (a) whether impairment, disability and social support deficits were associated with depression; (b) whether social support modified this association.

RESULTS

There were strong graded relationships between impairment, disability, social support deficits and EURO-D caseness. Level of impairment, but not disability, interacted with poor social support in that depression was especially likely in those who had more physical impairments as well as one or more social support deficits (p value for interaction=0.018), even after full adjustment.

CONCLUSIONS

Social support is important in reducing the association between physical impairment and depression in Thai older adults, especially for those with a large number of impairments. Enhancing social support as well as improving healthcare and disability facilities should be emphasized in interventions to prevent depression in older adults.

Prevalence and implications of psychopathological non-cognitive symptoms in dementia

OBJECTIVE

Clinical experience and recent population studies suggest that psychopathological, non-cognitive symptoms are both frequent and relevant in dementia.

METHOD

A representative community sample (n = 4,803 individuals, 55 + years) was interviewed in a two-phase design. The Geriatric Mental Sate (GMS) was used for assessment and cases were diagnosed according to DSM-IV-TR criteria.

RESULTS

The prevalence of non-cognitive symptoms (1 + symptoms) in cases of dementia (n = 223) was 90.1%, and negative-type symptoms were most frequently found. A GMS 'apathy-related symptom cluster' (anergia, restriction of activities and anhedonia) was significantly more frequent in the demented (55.6%) than in non-cases (0.7%; specificity = 99.2%). In both dementia of Alzheimer's type and vascular dementia, number of symptoms tended to be inversely related to severity of dementia, but psychopathological profiles differed.

CONCLUSION

Non-cognitive, negative-type symptoms are very frequent in cases of dementia living in the community. They have powerful specificity in the distinction with non-cases, and might change current concepts of dementia.

Prevalence and symptomatology of depression in older people living in institutions in England and Wales

BACKGROUND

Epidemiological studies have shown that depression is common in institutional settings. However, the symptomatology of depression in this group has not been compared to those living in the community.

AIMS

To estimate the prevalence of depression and depressive symptomatology in participants living in institutions and compare these to people living in other settings.

METHOD

The Medical Research Council Cognitive Function and Ageing Study (MRC CFAS) is a population-based cohort comprising 13,004 individuals aged 65 and above, from five sites across England and Wales. Following screening, a stratified random sub-sample of 2,640 participants received the Geriatric Mental State (GMS) examination of whom 340 resided in institutions. Diagnoses of depression were made using the Automated Geriatric Examination for Computer-assisted Taxonomy system (AGECAT).

RESULTS

The prevalence of depression in those living in institutions was 27.1% (95% CI 17.8-36.3) compared to 9.3% (95% CI 7.8-10.9) in those living at home. Symptoms relating to depressed mood, severity of illness (e.g. wishing to be dead, future looking bleak) and some non-specific symptoms were more common in those living in residential homes. Depression was significantly associated with younger age (P = 0.002) and high functional disability (P = 0.009) in those living in institutions.

CONCLUSIONS

Consistent with previous estimates, depression was highly prevalent in institutions, particularly in younger individuals with severe functional impairment. Those in institutions report considerably more symptoms of depression. Finding interventions which address these symptoms might improve quality of life for people in institutions, irrespective of formal diagnoses.

Physical health and depressive symptoms in older Europeans. Results from EURODEP

BACKGROUND

Associations between physical health and depression are consistent across cultures among adults up to 65 years of age. In later life, the impact of physical health on depression is much more substantial and may depend on sociocultural factors.

AIMS

To examine cross-national differences in the association between physical health and depressive symptoms in elderly people across western Europe.

METHOD

Fourteen community-based studies on depression in later life in nine western European countries contributed to a total study sample of 22 570 respondents aged 65 years and older. Measures were harmonized for depressive symptoms (EURO-D scale), functional limitations and chronic physical conditions.

RESULTS

In the majority of the participating samples, the association of depressive symptoms with functional disability was stronger than with chronic physical conditions. Associations were slightly more pronounced in the UK and Ireland.

CONCLUSIONS

The association between physical health and depressive symptoms in later life is consistent across western Europe.

Economic analysis of an early discharge rehabilitation service for older people

OBJECTIVE

to measure the cost-effectiveness of an early discharge and rehabilitation service (EDRS) in Nottingham, UK.

DESIGN

data were collected during a randomised controlled trial.

METHODS

cost and cost-effectiveness analyses were conducted from the perspective of service providers (health and social services) over a period of 12 months. Resource variables included were the EDRS intervention, the initial acute hospital admission (from randomisation), readmission to hospital, hospital outpatient visits, stays in nursing and residential homes, general practitioner contact, community health services and social services. The effectiveness measure was the EuroQol EQ-5D score, from which quality-adjusted life years (QALY) were calculated. Cost-effectiveness was calculated as cost per QALY gained.

RESULTS

at 12 months the mean untransformed total cost for the EDRS was 8,361 pound sterling compared to 10,088 pound sterling for usual care, a saving of 1,727 pound sterling (P = 0.05). Cost-effectiveness acceptability curves showed a high probability that the EDRS was cost effective across a range of monetary values for a QALY.

CONCLUSIONS

the Nottingham EDRS was likely to be more cost effective than usual care.

Effect of smoking on global cognitive function in nondemented elderly

BACKGROUND

Contrary to early case-control studies that suggested smoking protects against Alzheimer disease (AD), recent prospective studies have shown that elderly who smoke may be at increased risk for dementia.

OBJECTIVE

To examine prospectively the effect of smoking on cognition in nondemented elderly.

METHOD

In a multicenter cohort, the European Community Concerted Action Epidemiology of Dementia (EURODEM), including the Odense, Personnes Agées Quid (Paquid), Rotterdam, and Medical Research Council: Ageing in Liverpool Project-Health Aspects (MRC ALPHA) Studies, 17,610 persons aged 65 and over were screened and examined for dementia. After an average 2.3 years of follow-up, 11,003 nondemented participants were retested. Excluding incident dementia cases and those without baseline information on smoking gave an analytical sample of 9,209 persons. Average yearly decline in Mini-Mental State Examination (MMSE) score was compared among groups, adjusting for age, sex, baseline MMSE, education, type of residence, and history of myocardial infarction or stroke.

RESULTS

MMSE score of persons who never smoked on average declined 0.03 point/year. The adjusted decline of former smokers was 0.03 point greater and of current smokers 0.13 point greater than never smokers (p < 0.001). Higher rates of decline by smoking were found in men and women, persons with and without family history of dementia, and in three of four participating studies. Higher cigarette pack-year exposure was correlated with a significantly higher rate of decline.

CONCLUSION

Smoking may accelerate cognitive decline in nondemented elderly.

The Geriatric Mental State Examination in the 21st century

The Geriatric Mental State Examination (GMS) is now established as one of the most commonly used mental health assessments for older people. Its strengths lie in extensive validity studies, high inter-rater reliability, accessibility to trained raters, irrespective of professional background and its continual evolution and adaptation. Its computerisation, association with supplementary instruments and support by a diagnostic algorithm provides a comprehensive diagnostic system and syndrome profile for each subject. The instrument has been validated against most major diagnostic systems and has been used as outcome measures in intervention studies. It has been translated into numerous languages and validated as a diagnostic instrument in various cultures. Such studies have exposed weaknesses, including the over diagnoses of organic states in populations with poorly developed education. On-going studies continue to address these issues, providing a culture sensitive instrument enabling unique trans-cultural research in a relatively under-researched field.

Taking responsibility for cancer treatment

One hundred and fourteen consecutive patients with early breast cancer were entered into a study on the psychological effects of involvement in treatment choice. All women were offered counselling throughout. One group of women (n = 34), were advised to undergo mastectomy, due to the nature or position of the tumour. These women fared less well psychologically when compared on a battery of measures, before and after surgery, with women who were involved in choosing their own treatment (n = 80). The latter group itself was randomly allocated into two groups for taking explicit responsibility for treatment choice, using a double-blind procedure. These were a Patient Decision Group (n = 41) and a Surgeon Decision Group (n = 39). Results support the hypothesis that over and above the benefits of receiving their preferred treatment, women can further benefit from taking explicit responsibility for their treatment choice.

Diagnosis of dementia from the history and aetiology schedule

OBJECTIVE

To provide a computerised method of diagnosing organic brain syndrome from history data without the use of mental state data.

METHODS

Interview dataset from participants in a community study of the incidence of dementia was used to form a training sample and validation sample. The algorithm was developed on the training sample and tested on the validation sample.

RESULTS

Performance in the training and validation samples was very similar. The algorithm shows monotonically increasing probability of being diagnosed with dementia as a function of the proposed level of diagnostic confidence. At the proposed cut point it has sensitivity 94% and specificity 84% for detecting concurrent psychiatrist's diagnosis of dementia.

CONCLUSIONS

The method provides a good agreement with psychiatrist's diagnosis, and the results in the validation sample show little shrinkage. The method will prove useful in studies where it has proved impossible to collect mental state information on all the study participants.

Dementia, cognitive impairment and mortality in persons aged 65 and over living in the community: a systematic review of the literature

BACKGROUND

No recent attempt has been made to synthesise information on mortality and dementia despite the theoretical and practical interest in the topic. Our objective was to estimate the influence on mortality of cognitive impairment and dementia.

METHODS

Data sources were Medline, Embase, personal files and colleagues' records. Studies were considered if they included a majority of persons aged 65 and over at baseline either drawn from a total community sample or drawn from a random sample from the community. Samples from health care facilities were excluded. The search located 68 community studies. Effect sizes were extracted from the studies and if they were not included in the published studies, effect sizes were calculated where possible: this was possible for 23 studies of cognitive impairment and 32 of dementia. No attempt was made to contact authors for missing data.

RESULTS

For the studies of cognitive impairment Fisher's method (a vote counting method), gave a p-value (from eight studies) of 0.00001. For studies of dementia, age-adjusted confidence intervals (CI) were pooled (odds ratio (OR) 2.63 with 95% CI 2.17 to 3.21 from six studies).

CONCLUSIONS

Levels of cognitive impairment commonly found in community studies give rise to an increased risk of mortality, and this appears to be true even for quite mild levels of impairment. The analysis confirms the increased risk of mortality for dementia, but reveals a dearth of information on the causes of the excess mortality and on possible effect modification by age, dementia subtype or other variables.

Self-reported medication use for older people in England and Wales

OBJECTIVES

To describe the patterns of self-reported medication use, including both prescription and non-prescription drugs, for older people in five areas in England and Wales, and to identify the effects of socio-demographic features on medication use.

DESIGN

A cross-sectional survey on population random samples of people aged 65 and over. The survey is a part of the screening interviews at the first stage of the Medical Research Council Cognitive Function and Ageing Study (MRC CFAS) carried out between 1991 and 1994. The sample was stratified to provide equal numbers in the 65-74 years and 75 years and over age groups.

SETTING

Three urban (Newcastle, Nottingham and Oxford) and two rural (Cambridgeshire and Gwynedd) centres. Older people living in both the general community and institutions were included.

PARTICIPANTS

12489 older people whose medication data were collected among the 13009 participants of the CFAS, of which the participation rate is 80%.

RESULTS

Overall prevalence of medication use was 75% (95% confidence interval 74-76%) for people aged 65-74 and 84% (83-85%) for people aged 75 and over, with a mean number of 2.03 (standard deviation 1.95) and 2.47 (2.02) drugs reported per respondent in each group, respectively. Concurrent use of five or more drugs (polypharmacy) was found in 11% (10-12%) of people in the 65-74 age group and in 15% (14-16%) in the 75 and over age group. People aged 75 and over were more likely to be taking at least one drug than people aged 65-74 (OR=1.69, 1.54-1.85), and women were more likely to be so compared with men (OR=1.43, 1.30-1.56). Centre variation was found but none of the centres consistently showed higher or lower usage of medications across the major drug categories. People living in institutions were more likely to be taking gastrointestinal drugs, central nervous system drugs and experience polypharmacy. The use of respiratory and central nervous system drugs (except hypnotics and anxiolytics) increased in lower social class and decreased in people attending full-time education for 10 years or more. The use of haematology/dietetic drugs (85% of which were vitamin and mineral preparations) decreased in lower social class.

CONCLUSION

This study provides representative estimates of medication usage among older people in England and Wales and identified associated factors and regional variations for medication use in a category-specific manner. The findings, suggesting the existence of centre variation and the association between type of accommodation, social class and medication use warrant further investigation.

Depression, depressive symptoms and mortality in persons aged 65 and over living in the community: a systematic review of the literature

BACKGROUND

No recent attempt has been made to synthesize information on mortality and depression despite the theoretical and practical interest in the topic. Our objective was to estimate in the older population the influence on mortality of depression and depressive symptoms.

METHODS

Data sources were: Medline, Embase, personal files and colleagues' records. Studies were considered if they included a majority of persons aged > or = 65 years at baseline either drawn from a total community sample or drawn from a random sample from the community. Samples from healthcare facilities were excluded. Effect sizes were extracted from the papers; if they were not included in the published papers, effect sizes were calculated if possible. No attempt was made to contact authors for missing data.

RESULTS

We found 21 reports on 23 cohorts using depression diagnosis. For 15 of these, odds ratios were pooled using the Greenland method based on confidence intervals (CIs), giving an estimated odds ratio for mortality with depression of 1.73 (95% CI 1.53 to 1.95). A fixed effects meta-regression of these studies suggested that longer follow-up predicted smaller effect sizes (log odds ratios -0.096 per year (95% CI -0.179 to -0.014)). There is a weak suggestion of a reduced effect of depression on mortality for women. We were unable to pool effect sizes from the 17 studies using symptom totals and scales, or from eight studies of specific symptoms.

CONCLUSIONS

The studies show that diagnosed depression in community-resident older people is associated with increased mortality. The picture for sex differences is still unclear.

A multicentre randomized controlled trial of leisure therapy and conventional occupational therapy after stroke. TOTAL Study Group. Trial of Occupational Therapy and Leisure

OBJECTIVE

To evaluate the effects of leisure therapy and conventional occupational therapy (OT) on the mood, leisure participation and independence in activities of daily living (ADL) of stroke patients 6 and 12 months after hospital discharge.

DESIGN

Multicentre randomized controlled trial.

SETTING AND PARTICIPANTS

Four hundred and sixty-six stroke patients from five UK centres.

MAIN OUTCOME MEASURES

The General Health Questionnaire (12 item), the Nottingham Extended ADL Scale and the Nottingham Leisure Questionnaire, assessed by post, with telephone clarification.

RESULTS

Four hundred and forty (94%) and 426 (91%) subjects were alive at 6 and 12 months, respectively. Three hundred and seventy-four (85% of survivors) and 311 (78% of survivors) responded at 6 and 12 month follow-up respectively. At six months and compared to the control group, those allocated to leisure therapy had nonsignificantly better GHQ scores (-1.2: 95% CI -2.9, +0.5), leisure scores (+0.7, 95% CI -1.1, +2.5) and Extended ADL scores (+0.4: 95% CI -3.8, +4.5): the ADL group had nonsignificantly better GHQ scores (-0.1: 95% CI -1.8, +1.7) and Extended ADL scores (+1.4: 95% CI -2.9, +5.6) and nonsignificantly worse leisure scores (-0.3: 95% CI -2.1, +1.6). The results at 12 months were similar.

CONCLUSION

In contrast to the findings of previous smaller trials, neither of the additional OT treatments showed a clear beneficial effect on mood, leisure activity or independence in ADL measured at 6 or 12 months.

Education and the risk for Alzheimer's disease: sex makes a difference. EURODEM pooled analyses. EURODEM Incidence Research Group

The hypothesis that a low educational level increases the risk for Alzheimer's disease remains controversial. The authors studied the association of years of schooling with the risk for incident dementia and Alzheimer's disease by using pooled data from four European population-based follow-up studies. Dementia cases were identified in a two-stage procedure that included a detailed diagnostic assessment of screen-positive subjects. Dementia and Alzheimer's disease were diagnosed by using international research criteria. Educational level was categorized by years of schooling as low (< or =7), middle (8-11), or high (> or =12). Relative risks (95% confidence intervals) were estimated by using Poisson regression, adjusting for age, sex, study center, smoking status, and self-reported myocardial infarction and stroke. There were 493 (328) incident cases of dementia (Alzheimer's disease) and 28,061 (27,839) person-years of follow-up. Compared with women with a high level of education, those with low and middle levels of education had 4.3 (95% confidence interval: 1.5, 11.9) and 2.6 (95% confidence interval: 1.0, 7.1) times increased risks, respectively, for Alzheimer's disease. The risk estimates for men were close to 1.0. Finding an association of education with Alzheimer's disease for women only raises the possibility that unmeasured confounding explains the previously reported increased risk for Alzheimer's disease for persons with low levels of education.

Gender differences in the incidence of AD and vascular dementia: The EURODEM Studies. EURODEM Incidence Research Group

OBJECTIVE

To study the difference in risk for dementing diseases between men and women.

BACKGROUND

Previous studies suggest women have a higher risk for dementia than men. However, these studies include small sample sizes, particularly in the older age groups, when the incidence of dementia is highest.

METHODS

Pooled analysis of four population-based prospective cohort studies was performed. The sample included persons 65 years and older, 528 incident cases of dementia, and 28,768 person-years of follow-up. Incident cases were identified in a two-stage procedure in which the total cohort was screened for cognitive impairment, and screen positives underwent detailed diagnostic assessment. Dementia and main subtypes of AD and vascular dementia were diagnosed according to internationally accepted guidelines. Sex- and age-specific incidence rates, and relative and cumulative risks for total dementia, AD, and vascular dementia were calculated using log linear analysis and Poisson regression.

RESULTS

There were significant gender differences in the incidence of AD after age 85 years. At 90 years of age, the rate was 81.7 (95% CI, 63.8 to 104.7) in women and 24.0 (95% CI, 10.3 to 55.6) in men. There were no gender differences in rates or risk for vascular dementia. The cumulative risk for 65-year-old women to develop AD at the age of 95 years was 0.22 compared with 0.09 for men. The cumulative risk for developing vascular dementia at the age of 95 years was similar for men and women (0.04).

CONCLUSION

Compared with men, women have an increased risk for AD. There are no gender differences in risk for vascular dementia.

Undifferentiated dementia, Alzheimer's disease and vascular dementia: age- and gender-related incidence in Liverpool. The MRC-ALPHA Study

BACKGROUND

Does incidence of dementia follow the age pattern of prevalence? Is gender a risk factor? Do patterns of incidence differ between dementias?

AIMS

To assess age-specific incidence rates of undifferentiated dementias, Alzheimer's disease and vascular dementia.

METHOD

5222 individuals aged > or = 65 years, were interviewed using the Geriatric Mental State/History and Aetiology Schedule. The AGECAT package was used to identify cases at three interviewing waves at two-year intervals. Diagnoses were made using ICD-10 Research Criteria and validated against neurological and psychological examination, with imaging and neuropathology on unselected subsamples.

RESULTS

Incidence rates of the dementias increase with age. Age patterns are similar between Alzheimer's disease and vascular dementia. Gender appears influential in Alzheimer's disease. In England and Wales, 39,437 new cases of Alzheimer's disease (4.9/1000 person-years at risk); 20,513 of vascular dementia (2.6/1000 person-years) and 155,169 of undifferentiated dementia (19/1000 person-years) can be expected each year.

CONCLUSIONS

Incidence rates for Alzheimer's disease and vascular dementia appear to behave differently, with an increased risk of Alzheimer's disease for women compared to vascular dementia.

Community-based case-control study of depression in older people. Cases and sub-cases from the MRC-ALPHA Study

BACKGROUND

Risk factors of depression in later life, particularly for sub-cases and for psychotic and neurotic types of depression, are unclear.

AIMS

To identify such risk factors.

METHOD

Over 5200 older people (> or = 65 years), randomly selected from Liverpool, were interviewed using the Geriatric Mental State (GMS) and the Minimum Data Set (MDS). The computer-assisted diagnosis AGECAT identified 483 cases and 575 sub-cases of depression and 2451 with no mental problems. Logistic regression was employed to examine factors relevant to caseness.

RESULTS

In multiple logistical regression, odds ratios (ORs) were significantly high for being female (2.04, 95% CI 1.56-2.69), widowed (2.00, 1.18-3.39), having alcohol problems (4.37, 1.40-2.94), physical disablement (2.03, 1.40-2.94), physical illness (1.98, 1.25-3.15), taking medications to calm down (10.04, 6.41-15.71), and dissatisfaction with life (moderate 4.54, 3.50-5.90; more severe 29.00, 16.00-52.59). Good social networks reduced the ORs. If sub-cases were included as controls, the statistical significance was reduced.

CONCLUSIONS

Age was not associated with depression in later life whereas gender, physical disablement and dissatisfaction with life were. The sub-cases shared many risk factors with cases, suggesting that prevention may need to be attempted at an early stage.

Cross-cultural comparison of depressive symptoms in Europe does not support stereotypes of ageing

BACKGROUND

Stereotypes of older people suggest that they are depressed.

AIMS

To examine depression symptoms among people aged > or = 65 in the general population and to ask the following questions. Are there high proportions of depressive symptoms among otherwise well people? Do these levels reflect the prevalence of depression? Do key symptoms vary with age and do they confirm stereotypes?

METHOD

Nine centres contributed data from community-based random samples, using standardised methods (GMS-AGECAT package).

RESULTS

Proportions of depressive symptoms varied between centres. Some often associated with ageing were rare. Many were more common in women. Low-prevalence centres tended to have fewer symptoms among 'well' people, but there were inconsistencies. Low levels of symptoms among the well population of a centre did not necessarily predict lower levels in the depressed.

CONCLUSIONS

Variations in the prevalence of depressive symptoms occurred between centres, not always related to levels of illness. There was no consistent relationship between proportions of symptoms in well persons and cases for all centres. Few symptoms were present in > 60% of the older population--stereotypes of old age were not upheld.

Depression in Europe. Geographical distribution among older people

BACKGROUND

This is the first report of results from the EURODEP Programme.

AIMS

To assess the prevalence of depression judged suitable for intervention in randomised samples of those aged > or = 65 in nine European centres.

METHOD

The GMS-AGECAT package.

RESULTS

Differences in prevalence are apparent, 8.8% (Iceland) to 236% (Munich). When sub-cases and cases are added together, five high- and four low-scoring centres emerge. Women predominated over men. Proportions of sub-cases to cases revealed striking differences but did not explain prevalence. There was no constant association between prevalence and age. A meta-analysis (n = 13,808) gave an overall prevalence of 12.3%, 14.1% for women and 8.6% for men.

CONCLUSIONS

Considerable variation occurs in the levels of depression across Europe, the cause for which is not immediately obvious. Case and sub-case levels taken together show greater variability, suggesting that it is not a matter of case/sub-case selection criteria, which were standardised by computer. Substantial levels of depression are shown but 62-82% of persons had no depressive level. Opportunities for treatment exist.

Rates and risk factors for dementia and Alzheimer's disease: results from EURODEM pooled analyses. EURODEM Incidence Research Group and Work Groups. European Studies of Dementia

OBJECTIVE

To investigate the risk of AD associated with a family history of dementia, female gender, low levels of education, smoking, and head trauma.

BACKGROUND

These putative factors have been identified in cross-sectional studies. However, those studies are prone to bias due to systematic differences between patients and control subjects regarding survival and how risk factors are recalled.

METHODS

The authors performed a pooled analysis of four European population-based prospective studies of individuals 65 years and older, with 528 incident dementia patients and 28,768 person-years of follow-up. Patients were detected by screening the total cohort with brief cognitive tests, followed by a diagnostic assessment of those who failed the screening tests. Dementia was diagnosed with the Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. (revised), and AD was diagnosed according to National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association criteria. Incident rates and relative risk (95% CI) express the association of a risk factor for dementia.

RESULTS

Incident rates for dementia and AD were similar across studies. The incidence of AD increased with age. At 90 years of age and older the incidence was 63.5 (95% CI, 49.7 to 81.0) per 1,000 person-years. Female gender, current smoking (more strongly in men), and low levels of education (more strongly in women) increased the risk of AD significantly. A history of head trauma with unconsciousness and family history of dementia did not increase risk significantly.

CONCLUSION

Contrary to previous reports, head trauma was not a risk factor for AD, and smoking did not protect against AD. The association of family history with the risk of AD is weaker than previously estimated on the basis of cross-sectional studies. Female gender may modify the risk of AD, whether it be via biological or behavioral factors.

Do experienced diagnosticians agree about the diagnosis of dementia from survey data? The effects of informants' reports and interviewers' vignettes

Dementia in community settings is often diagnosed by computerized algorithms. This study examines the extent to which independent diagnosticians agreed among themselves in diagnosing dementia, severity and type when presented with data obtained during a population-based incidence study of cognitive decline and dementia. Secondly, it examines how judgements, based initially on respondents' self-reports and cognitive performance, were affected first by informants' reports and then by short case-vignettes written by trained lay interviewers. Thirdly, it compares diagnosticians' diagnosis of dementia with the algorithmic diagnosis (AGECAT). The items presented were selected from two screening interviews at wave 1 and wave 2 separated by an interval of 2 years and from wave 2 assessment and informant interviews, and included medical, psychiatric and ADL items and interviewers' own observations. The sample (N = 42) was derived from the first year of the wave 2 assessments, potential dementia cases entering consecutively while presumed normals were selected randomly. Informants were available in 30. Agreement on diagnosis and type of dementia improved with increasing information, particularly from informants, but remained poor regarding severity. The number of cases of dementia, defined operationally, increased from 10 to 12 and uncertain cases fell from eight to six, but no respondent initially diagnosed as a dementia case was rediagnosed as a non-case, or vice versa. Dementia type changed from agreement about Alzheimer's disease to agreement about vascular dementia in one case. Operational and algorithmic diagnoses showed good agreement. Causes of disagreement, the role of vignettes and the relevance of the results for population surveys are discussed.

Outcome of the depressed elderly living in the community in Liverpool: a 5-year follow-up

BACKGROUND

Comparatively little is known about the long-term natural history of depressive disorders in the elderly living in the community. This is a follow-up of a subsample of the Continuing Health in the Community study random sample of the elderly population living in Liverpool.

METHODS

The investigators followed up 120 cases of depression identified by a semi-structured interview schedule (GMS) for a period of 5 years. A similar number of other subjects defined as subcases of depression, other cases of mental illness and a random selection of non-cases were also included.

RESULTS

The 5-year outcome for the cases of depression was worse than the outcome of the non-cases (relative mortality risk of 2.1, 95% confidence interval 1.1 to 3.9). Thirty-four per cent of the cases of depression died and 28% had dropped out during the follow-up. Of the 46 cases of depression who had a complete follow-up, 22% recovered from their symptoms, 30% were found to be AGECAT cases at one of the three follow-up waves, 24% were AGECAT cases at two of the three follow-up waves and the remaining 24% were AGECAT cases at each follow-up wave. Fifteen per cent of the surviving cases of depression were organic cases at the follow-up. Their anxiety comorbid state and depression score were identified as predictors of poor outcome.

CONCLUSION

The findings of this study indicate that depressive disorders (most of which were untreated) found in the elderly community have a poor prognosis.

Schizophrenia and delusional disorder in older age: community prevalence, incidence, comorbidity, and outcome

The opportunity to assess prevalence, incidence, and outcome of schizophrenia and delusional disorder was provided by an age- and sex-stratified random sample of 5,222 persons age 65 years and over. This sample was chosen from general practitioner lists, and interviewed by psychiatric nurses trained to use the Geriatric Mental State (GMS)-AGECAT computerized diagnostic system. GMS-AGECAT ensured the reliability of the selection of cases between the two waves of the study. A subsample was interviewed by a research psychiatrist. The sample was followed up 2 years later using the same method by interviewers blind to the initial findings. The protocols of all nominated cases and subcases of schizophrenia/paranoid disorder diagnosed by AGECAT were reviewed by a clinician and DSM-III-R diagnoses were made. Refusal rate was 13 percent for initial interviews (wave 1) and 15 percent for reinterview 2 years later (wave 2). The prevalence of DSM-III-R schizophrenia was 0.12 percent (95% confidence interval [CI] 0.04-0.25) and delusional disorder 0.04 percent (95% CI 0.00-0.14). The minimum incidence of schizophrenia for new cases was 3.0 (95% CI 0.00 to 110.70); for new and relapsed cases, 45.0 (95% CI 3.54-186.20); and for delusional disorder, 15.6 (95% CI 0.02-135.10) per 100,000 per year. Two of the five cases with schizophrenia were known to have been first diagnosed before age 65. After 2 years, none of the cases of schizophrenia had recovered fully, but none was deluded at followup. Two had developed dementia. The outcome was bad because they remained cases of some type of psychiatric illness but good because of the improvement in their schizophrenia/delusion disorder symptoms.

Physical illness and disability among elderly people in England and Wales: the Medical Research Council Cognitive Function and Ageing Study. The Analysis Group

STUDY OBJECTIVE

This study was conducted as part of the MRC cognitive function and ageing study. It aimed to estimate the lifetime prevalence of self reported physical illnesses and other health related events, and the prevalence of limiting disability in people over 65 in six areas of England and Wales.

DESIGN

Screening phase of a two stage prevalence study.

SETTING

Geographically delimited areas in four urban and two rural areas including institutions.

PARTICIPANTS

Random population samples of people in their 65th year and above on the sample definition date, interviewed between 1989 and 1994. In Newcastle, Nottingham, and Oxford (urban) and in Cambridgeshire and Gwynedd(rural), the sample was stratified to provide equal numbers in the 65-74 and 75 years and over age groups. In Liverpool (urban), equal numbers in the five year age groups were taken.

MAIN RESULTS

Age standardised prevalences were calculated for each geographical area, sex, and age group (65-74, 75+). Many conditions were more prevalent in the older age group including stroke, Parkinson's disease, arthritis, diabetes, and shingles but hypertension was more common in the younger age group. Conditions that were more prevalent in men included angina, heart attack, stroke, head injury, and peptic ulcers while hypertension, shingles, pernicious anaemia, and thyroid disease were more common in women. There was a complex pattern of area differences for individual conditions. Cambridgeshire had generally low prevalences for many diseases, including vascular problems, Gwynedd and Newcastle had less healthy elderly populations, and Nottingham and Newcastle had the highest percentages of housebound.

CONCLUSIONS

This study provides the most robust available estimates for life-time prevalence of a variety of health conditions on a regional and national basis. It shows the greatly increased prevalence of disability in the very old population, particularly women.

Two predictions about paranoid ideation: deluded, depressed and normal participants' subjective frequency and consensus judgments for positive, neutral and negative events

Two groups of patients suffering from persecutory delusions, one consisting of patients also suffering from depression and a non-depressed group, together with clinically depressed and normal controls matched with the deluded patients for age and intelligence, were asked to rate the frequency with which selected positive, negative and neutral events had happened to themselves and to an average other person in the past, and the frequency with which these events were likely to happen to themselves and to an average other person in the future. Results were similar for both past and expected future events. Non-depressed-deluded, depressed-deluded and depressed patients rated negative events as occurring relatively more frequently in comparison to the normal controls. Depressed participants rated positive events as occurring more frequently to others, whereas the normal participants rated negative events as occurring more often to others. Correlational analyses indicated that depression scores were associated with low estimates of the frequency with which positive events happen to self and high estimates of the frequency with which negative events happen to self. Magical ideation scores, an index of psychosis, were associated with high estimates of the frequency of negative events for both self and others. These findings are interpreted in the context of previous evidence on cognitive biases in deluded patients.

Maternal attachment status, psychosocial stressors and problem behaviour: follow-up after parent training courses for conduct disorder

37 Mothers of children with conduct disorder who had received Parent Management Training (PMT) were interviewed using the Adult Attachment Interview, 13-43 months after treatment. Child behaviour levels at follow-up were strongly associated with the scores at referral in the unresolved attachment group, but not in the resolved group. This was reflected in a statistical interaction between referral behaviour score and resolved/unresolved attachment status in a regression model. This model, which also included a strong independent contribution from a composite psychological stress index, explained 66% of the variance in follow-up behaviour scores. The implications of these results for predicting the outcome of PMT are discussed.

Blood pressure as a risk factor for depression in elderly people: a prospective study

A total of 1070 men and women aged 65 years and over living in the community in Liverpool were interviewed using the Geriatric Mental State. Diagnoses of depression at case and subcase level were made using the GMS-AGECAT package from an initial interview and at follow-up three years later. Data relating to blood pressure at year 0 was available on 748 subjects. Men not taking anti-hypertensives or antidepressants with diastolic blood pressure greater than 85 mmHg were significantly less likely to be subcases than men with low or normal diastolic pressure. People in this group were also significantly less likely to be cases 3 years later. There were no other significant findings. These results do not support an association between low blood pressure and coincidental or future subcase- or case-level depressive illness.

Cross-national comparison of prevalence of symptoms of neurotic disorders in older people in two community samples

The objective of this research was to compare the prevalence of symptoms characteristic of neurotic disorders in two different cultural settings. The design was two random community samples in Liverpool (United Kingdom) and Zaragoza (Spain), of 1070 and 1080 people aged 65 and over. The main outcome measures were the rating of symptoms on the Geriatric Mental State and syndrome levels using the Automated Geriatric Examination for Computer Assisted Taxonomy. The results showed substantial differences between the two cities in the symptomatic pattern of phobias, but both the symptomatic and syndrome presentation of obsessional, hypochrondriacal and anxiety disorders were much more similar.

Affective disorders among elderly general practice patients. A two-phase survey in Brescia, Italy

BACKGROUND

We investigated the prevalence of depression among 255 elderly general practice patients and the practitioners' performance in identifying depression.

METHOD

Elderly patients attending 14 general practices entered a screening phase with GHQ-12 and MMSE. Those positive were then interviewed with GMS and HAS.

RESULTS

DSM-III-R major depression affected 22.4%, dysthymic disorder 6.3%, not otherwise specified (n.o.s.) depression 7.1%. General practitioners performed fairly well: identification index 88.4%, accuracy 0.49, bias 1.85.

CONCLUSIONS

Depression was markedly high. A selective progression of depressed elderly from the community to general practitioners is implied.

Preliminary development of a questionnaire designed to measure neurotic perfectionism in the eating disorders

The preliminary development and validation of a new self-report questionnaire (the NPQ) for measuring neurotic perfectionism in the eating-disorder population is described. The 42-item instrument demonstrated satisfactory internal consistency. All test items correlated significantly with both SCANS P and SCANS D (subscales of the SCANS [Slade & Dewey, 1986]), thus indicating neurotic perfectionism according to Slade, Newton, Butler, and Murphy (1991), and discriminated well between controls and eating-disorder patients. NPQ scores demonstrated significant group differences on comparison of neurotic perfectionists with normal and non-perfectionists (defined by the SCANS) and with subjects who scored above the EAT-26 (Garner, Olmsted, Bohr, & Garfinkel, 1982) subscale cut-offs when compared with those who scored below.

Development of a novel scale to assess life fulfillment as part of the further refinement of a quality-of-life model for epilepsy

We have been involved in developing a health-related quality-of-life model for use as an outcome measure in epilepsy. As part of the further development of this model, we have developed a measure of life fulfillment. This scale is based on methods previously described by Krupinski in 1980. The value of Krupinski's approach is the opportunity for patients to weight the numerous aspects of their quality of life and assess the discrepancy between their actual and desired circumstances. The life fulfillment scale has been shown to be reliable (alpha = 0.7) and valid. The scale is currently being applied to several clinical studies in epilepsy. We believe that the scale provides a valuable contribution to our health-related quality-of-life model.

The differential response of chronic fatigue, neurotic and muscular dystrophy patients to experimental psychological stress

A group of patients suffering from chronic fatigue (CF) attending a medical clinic were compared with a group of muscular dystrophy (MD) patients from the same clinic and a psychiatric control (PC) group who were attending a psychiatric unit. A checklist was used to assess the patients' subjective physical and psychological state before and after exposure to a psychological stressor. For both physical and psychological symptoms the CF group had the largest response, the PC group was intermediate, and the MD group had the least response. Explanations may involve physiological arousal and attentional focusing.

The prevalence of dementia, depression and neurosis in later life: the Liverpool MRC-ALPHA Study

Prevalence rates for psychiatric disorders in the elderly are presented from the initial cross-sectional stage of a longitudinal community study of the incidence of dementia in the city of Liverpool. Together with five other centres in the UK the MRC-ALPHA project forms part of the MRC multicentre incidence study of dementia and cognitive decline. An age- and sex-stratified random sample of 5222 subjects aged > or = 65 was interviewed at home using the Geriatric Mental State-AGECAT package to provide computer diagnoses. The overall age-standardized prevalence rates for organic disorder (4.7%) depressive illness (10.0%) and the neuroses (2.5%) are consistent with levels found in previous smaller studies that have used GMS-AGECAT. Each of these diagnoses is more common in females than males. A rise in organic disorder with age is confirmed as continuing into the oldest age groups for both sexes. An apparent decline with age observed for depression and neurosis diagnoses disappears when organic cases are excluded from the analysis.

Cross-cultural comparison of depression and depressive symptoms in older people

This article presents data on the prevalence of depression and the profile of depressive symptoms in 2 groups of people aged 65 and over: 1070 living in Liverpool, United Kingdom, and 1080 living in Zaragoza, Spain. Similar prevalence figures were found for women (Liverpool first); 14.2% vs 14.8% and, for men, 7.2% vs 6.2%. No age differences were found. The figures are lower than those found using similar methods in London and New York, but higher than those from Iceland. The article also compares the profile of depressive symptoms between Liverpool and Zaragoza and explains these by reference to social and cultural differences.

Prospective data on the prevalence of abnormal involuntary movements among elderly people living in the community

Trained raters from the Liverpool Continuing Health in the Community study interviewed 1070 people over the age of 65 in 1982-1983 using the Geriatric Mental State (GMS) examination. Three years later the cohort was re-interviewed, this time by psychiatrists trained in the GMS, who used the GMS and the History and Aetiology Schedule (HAS). The cohort had fallen in size to 875, because of mortality; 701 were re-interviewed. The cohort was followed up again 6 years after the first interview by trained nurse raters using the GMS (A3) and the Mini-Mental State Examination. Cases of mental disorder identified by the computer diagnostic program AGECAT were re-interviewed by psychiatrists along with a number of controls using the GMS and the HAS on the remaining 450 individuals. Observational behavioural ratings from the GMS and summary sheets were analysed along with AGECAT diagnoses and data on medication gained at the 3 assessments. The community prevalence of tardive dyskinesia and other movement disorders in elderly people over a 6-year follow-up appears to be very low (the community prevalence of tardive dyskinesia being 0.22% and akathisia 1.57%), is usually associated with organic mental disorder (and consequently higher mortality) and is furthermore not usually associated with antipsychotic medication.

Expressed wish to die and mortality in older people: a community replication

Three-year mortality of 1063 community residents aged 65 and over interviewed with the Geriatric Mental State Schedule was analysed to examine the influence of specific depression symptoms and physical illness in order to test theoretical predictions from models proposed by Macdonald and Dunn, and by Jorm and colleagues. Expressed wish to die was confirmed as a predictor of mortality, controlling for age, sex, and cognitive impairment. The suggestion that the effect of depressive symptoms on mortality might be a masked effect of physical illness was not confirmed. In general the more specific severe symptoms were better predictors of mortality.

Authors have rights too

Without publication research can be of little value. When researchers approach publication there is ample published guidance for them on what their obligations are, and there are well known style guides within each scientific discipline including, in medicine, the Vancouver style. This article gives a series of anonymous examples to suggest that the impact of similar guides for editors has been patchy and to make some suggestions for better communication.

A follow-up study of problem drinkers offered a goal choice option

Patients (N = 100) who had been admitted to behaviorally oriented residential treatment for their drinking problems were followed up for 1 year. A treatment goal option of controlled drinking was explicitly catered for. Overall outcome, in which 27% of those available for follow-up were categorized as "successful," 35% as "equivocal" and 38% as "failure," does not appear to be markedly dissimilar to that reported from other agencies. The distribution of approximately equal abstinent and nonabstinent successful outcomes is similar to that found following treatment programs that promote a single goal. Sociodemographic variables were less influential in predicting outcome than were treatment variables--with frequency of aftercare attendance being particularly significant. Those who had received previous hospital treatment for their problem, those who habitually drank in company and those who had abnormal blood test results prior to entering treatment had poorer outcome.

Pterin metabolism in depression: an extension of the amine hypothesis and possible marker of response to ECT

Urinary excretion of neopterins and biopterins was measured in 23 patients with severe depression before and after receiving electroconvulsive therapy (ECT) and 26 healthy control subjects. Patients with psychotic depression and those responding to ECT had neopterin:biopterin (N:B) ratio significantly higher than controls before commencing ECT and positive therapeutic response was associated with reduction of N:B ratio towards control values. As a raised N:B ratio implies failure to convert neopterin to biopterin it is possible that reduced availability of tetrahydrobiopterin, the essential cofactor for the formation of noradrenaline, serotonin and dopamine, may exert rate limiting control over the synthesis of monoamines implicated in the pathogenesis of depressive disorders. The N:B ratio may be a marker for certain depressive subtypes and response to ECT.

Risk factors for depression in elderly people: a prospective study

In 1982-1983 a random sample of 1486 people aged 65 years and above was generated from general practitioner lists; 1070 were interviewed in the community using the Geriatric Mental State and a Social History questionnaire. The cohort was followed up by interview 3 years later. At year 3 the diagnostic computer program AGECAT diagnosed 44 incident cases of depression. Information from the depressed group's initial and further interviews was compared with a control group (which excluded cases of affective or organic mental illness). Univariate analysis yielded three factors that were significantly associated with the development of depression 3 years later: a lack of satisfaction with life; feelings of loneliness; and smoking. Multivariate analysis confirmed their independent effects and revealed 2 further factors attaining significance: female gender and a trigger factor, bereavement of a close figure within 6 months of the third-year diagnosis. Some other factors traditionally associated with depression, such as poor housing, marital status and living alone, failed to attain significance as risk factors.