The association of white matter connectivity with prevalence, incidence and course of depressive symptoms: The Maastricht Study

BACKGROUND

Altered white matter brain connectivity has been linked to depression. The aim of this study was to investigate the association of markers of white matter connectivity with prevalence, incidence and course of depressive symptoms.

METHODS

Markers of white matter connectivity (node degree, clustering coefficient, local efficiency, characteristic path length, and global efficiency) were assessed at baseline by 3 T MRI in the population-based Maastricht Study (n = 4866; mean ± standard deviation age 59.6 ± 8.5 years, 49.0% women; 17 406 person-years of follow-up). Depressive symptoms (9-item Patient Health Questionnaire; PHQ-9) were assessed at baseline and annually over seven years of follow-up. Major depressive disorder (MDD) was assessed with the Mini-International Neuropsychiatric Interview at baseline only. We used negative binominal, logistic and Cox regression analyses, and adjusted for demographic, cardiovascular, and lifestyle risk factors.

RESULTS

A lower global average node degree at baseline was associated with the prevalence and persistence of clinically relevant depressive symptoms [PHQ-9 ⩾ 10; OR (95% confidence interval) per standard deviation = 1.21 (1.05-1.39) and OR = 1.21 (1.02-1.44), respectively], after full adjustment. On the contrary, no associations were found of global average node degree with the MDD at baseline [OR 1.12 (0.94-1.32) nor incidence or remission of clinically relevant depressive symptoms [HR = 1.05 (0.95-1.17) and OR 1.08 (0.83-1.41), respectively]. Other connectivity measures of white matter organization were not associated with depression.

CONCLUSIONS

Our findings suggest that fewer white matter connections may contribute to prevalent depressive symptoms and its persistence but not to incident depression. Future studies are needed to replicate our findings.

The effects of selective serotonin reuptake inhibitors on memory functioning in older adults: A systematic literature review

INTRODUCTION

Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed to older adults. In contrast to young subjects, it is unclear whether older adults may be vulnerable to cognitive side effects. Serotonin is involved in cognitive functions (e.g. memory). It is of great importance to examine the effects of SSRIs on memory functioning in older adults.

OBJECTIVES

The objective of this systematic literature review is to summarize studies in which the effects of SSRI treatment on all aspects of memory functioning in older adults are investigated.

METHODS

PubMed, PsycINFO, CINAHL, and Embase were searched for all studies published until 18th of October 2021. Articles were included if they fulfilled the inclusion criteria as follows: (1) study design is (randomized) controlled trial, cross-sectional, or prospective cohort study; (2) study population consists of older adults (mean age ⩾65 years), or results for this age-group are reported separately; (3) intervention is use of an SSRI; and (4) effects on performance of any memory domain are measured and clearly described.

RESULTS

The search yielded 1888 articles, of which 136 were included for the full-text review. Eventually, 40 articles were included. Most studies reported no association between SSRI use and memory functioning. The studies that found a positive association mainly investigated older adults with mental or neurological disorders (e.g. depression or stroke). A few studies found a negative association in the following subgroups: non-responders (depression), patients with frontal brain disease, and women.

CONCLUSION

Overall, no consistent negative effects of SSRIs on memory functioning in older adults were found after SSRI treatment. Most studies reported no change in memory functioning after SSRI use. Some studies even showed an improvement in memory performance. Positive effects of SSRIs on memory functioning were especially found in older adults with mental or neurological disorders, such as subjects with depression or stroke.

Optimal Detection of Subtle Gadolinium Leakage in CSF with Heavily T2-Weighted Fluid-Attenuated Inversion Recovery Imaging

Pericortical enhancement on postcontrast FLAIR images is a marker for subtle leptomeningeal blood-brain barrier leakage. We explored the optimal FLAIR sequence parameters for the detection of low gadolinium concentrations within the CSF. On the basis of phantom experiments and human in vivo data, we showed that detection of subtle pericortical enhancement can be facilitated by using a relatively long TE. Future studies should choose their FLAIR sequence parameters carefully when assessing pericortical enhancement due to subtle blood-brain barrier leakage.

The use of an electronic clinical rule to discontinue chronically used benzodiazepines and related Z drugs

PURPOSE

The chronic use of benzodiazepines and benzodiazepine-related drugs (BZ/Z) in older people is common and not without risks. The objective of this study was to evaluate whether the implementation of a clinical rule promotes the discontinuation of chronically used BZ/Z for insomnia.

METHODS

A clinical rule, generating an alert in case of chronic BZ/Z use, was created and applied to the nursing home (NH) setting. The clinical rule was a one-off intervention, and alerts did not occur over time. Reports of the generated alerts were digitally sent to NH physicians with the advice to phase out and eventually stop the BZ/Z. In cases where the advice was adopted, a follow-up period of 4 months on the use of BZ/Z was taken into account in order to determine whether the clinical rule alert led to a successful discontinuation of BZ/Z.

RESULTS

In all, 808 NH patients were screened. In 161 (19.1%) of the patients, BZ/Z use resulted in a clinical rule alert. From these, the advice to phase out and stop the BZ/Z was adopted for 27 patients (16.8%). Reasons for not following the advice consisted of an unsuccessful attempt in the past (38 patients), patients family and/or patient resistance (37 patients), the non-continuous use of BZ/Z (32 patients) and indication still present (27 patients). Of the 12 NH physicians, seven adopted the advice.

CONCLUSIONS

The success rate of a clinical rule for discontinuation of chronically used BZ/Z for insomnia was low, as reported in the present study. Actions should be taken to help caregivers, patients and family members understand the importance of limiting BZ/Z use to achieve higher discontinuation rates.

Pericortical Enhancement on Delayed Postgadolinium Fluid-Attenuated Inversion Recovery Images in Normal Aging, Mild Cognitive Impairment, and Alzheimer Disease

BACKGROUND AND PURPOSE

Breakdown of BBB integrity occurs in dementia and may lead to neurodegeneration and cognitive decline. We assessed whether extravasation of gadolinium chelate could be visualized on delayed postcontrast FLAIR images in older individuals with and without cognitive impairment.

MATERIALS AND METHODS

Seventy-four individuals participated in this study (15 with Alzheimer disease, 33 with mild cognitive impairment, and 26 with normal cognition). We assessed the appearance of pericortical enhancement after contrast administration, MR imaging markers of cerebrovascular damage, and medial temporal lobe atrophy. Three participants who were positive for pericortical enhancement (1 with normal cognition and 2 with mild cognitive impairment) were followed up for approximately 2 years. In vitro experiments with a range of gadolinium concentrations served to elucidate the mechanisms underlying the postcontrast FLAIR signals.

RESULTS

Postcontrast pericortical enhancement was observed in 21 participants (28%), including 6 individuals with Alzheimer disease (40%), 10 with mild cognitive impairment (30%), and 5 with normal cognition (19%). Pericortical enhancement was positively associated with age (P < .02) and ischemic stroke (P < .05), but not with cognitive status (P = .3). Foci with enhanced signal remained stable across time in all follow-up cases. The in vitro measurements confirmed that FLAIR imaging is highly sensitive for the detection of low gadolinium concentrations in CSF, but not in cerebral tissue.

CONCLUSIONS

Postcontrast pericortical enhancement on FLAIR images occurs in older individuals with normal cognition, mild cognitive impairment, and dementia. It may represent chronic focal superficial BBB leakage. Future longitudinal studies are needed to determine its clinical significance.

DNMT3A moderates cognitive decline in subjects with mild cognitive impairment: replicated evidence from two mild cognitive impairment cohorts

Epigenetic dysregulation has been associated with cognitive decline and Alzheimer's disease. The present study investigated associations between common SNPs in genes regulating DNA methylation and age-related changes in cognitive decline in two independent prospective cohorts of patients suffering from mild cognitive impairment. An association between the rs1187120 SNP in DNMT3A and annual decline in cognitive functioning was discovered and replicated, suggesting that DNMT3A moderates cognitive decline in subjects with mild cognitive impairment.

Systematic review and collaborative recalculation of 133,693 incident cases of schizophrenia

BACKGROUND

This systematic review and collaborative recalculation was set up to recalculate schizophrenia incidence rates from previously published studies by age and sex.

METHOD

PubMed, EMBASE and PsycINFO databases were searched (January 1950 to December 2009) for schizophrenia incidence studies. Numerator and population data were extracted by age, sex and, if possible, study period. Original data were requested from the authors to calculate age- and sex-specific incidence rates. Incidence rate ratios (IRRs) with their 95% confidence intervals (CIs) were computed by age and sex from negative binomial regression models.

RESULTS

Forty-three independent samples met inclusion criteria, yielding 133 693 incident cases of schizophrenia for analysis. Men had a 1.15-fold (95% CI 1.00-1.31) greater risk of schizophrenia than women. In men, incidence peaked at age 20-29 years (median rate 4.15/10,000 person-years, IRR 2.61, 95% CI 1.74-3.92). In women, incidence peaked at age 20-29 (median rate 1.71/10,000 person-years, IRR 2.34, 95% CI 1.66-3.28) and 30-39 years (median rate 1.24/10,000 person-years, IRR 2.25, 95% CI 1.55-3.28). This peak was followed by an age-incidence decline up to age 60 years that was stronger in men than in women (χ² = 57.90, p < 0.001). The relative risk of schizophrenia was greater in men up to age 39 years and this reversed to a greater relative risk in women over the age groups 50-70 years. No evidence for a second incidence peak in middle-aged women was found.

CONCLUSIONS

Robust sex differences exist in the distribution of schizophrenia risk across the age span, suggesting differential susceptibility to schizophrenia for men and women at different stages of life.

The impact of fatigue on cognitive functioning in patients with multiple sclerosis

Objective: To study the impact of physical and mental fatigue on cognitive complaints and cognitive performance in patients with multiple sclerosis.

Design: Cross-sectional study.

Setting: An outpatient neurology clinic.

Subjects: Eighty patients diagnosed with clinically definite multiple sclerosis.

Measures: The subscales physical and mental fatigue of the Multidimensional Fatigue Inventory; the Hospital Anxiety and Depression Scale and the Cognitive Failure Questionnaire. Cognitive performance was assessed by an extensive neuropsychological test battery, including several tasks requiring effortful information processing.

Results: Both anxiety and depression and mental fatigue significantly contributed to cognitive complaints, explaining respectively about 9% and 39% of the total variance. The contribution of physical fatigue to cognitive complaints was not significant. Both physical and mental fatigue did not significantly contribute to cognitive performance in terms of mental speed, attention, memory and executive functioning.

Conclusions: To refine interventions for those patients with cognitive complaints, we advise adding measurements of anxiety, depression and fatigue to their neuropsychological assessment. Fatigue permits extensive neuropsychological assessment, which is needed to detect cognitive impairment in multiple sclerosis.

Research protocol of the NeedYD-study (Needs in Young onset Dementia): a prospective cohort study on the needs and course of early onset dementia

BACKGROUND

Early onset dementia has serious consequences for patients and their family members. Although there has been growing attention for this patient group, health care services are still mainly targeted at the elderly. Specific knowledge of the needs of early onset dementia patients and their families is limited but necessary for the development of adequate health care services and specific guidelines. This research project is mainly targeted at delineating the course of early onset dementia, the functional characteristics and needs of early onset dementia patients and their caregivers, the risk factors for institutionalization and the interaction with the caring environment.

METHODS/DESIGN

The NeedYD-study (Needs in Young Onset Dementia) is a longitudinal observational study investigating early onset dementia patients and their caregivers (n = 217). Assessments are performed every six months over two years and consist of interviews and questionnaires with patients and caregivers. The main outcomes are (1) the needs of patients and caregivers, as measured by the Camberwell Assessment of Needs for the Elderly (CANE) and (2) neuropsychiatric symptoms, as measured by the NeuroPsychiatric Inventory (NPI). Qualitative analyses will be performed in order to obtain more in-depth information on the experiences of EOD patients and their family members. The results of this study will be compared with comparable data on late onset dementia from a historical cohort.

DISCUSSION

The study protocol of the NeedYD-study is presented here. To our knowledge, this study is the first prospective cohort study in this research area. Although some limitations exist, these do not outweigh the strong points of this study design.

The practical use of goal attainment scaling for people with acquired brain injury who receive cognitive rehabilitation

Objective: To examine the feasibility of and clinical experiences with goal attainment scaling when used for the evaluation of cognitive rehabilitation in people with acquired brain injury.

Design: A prospective observational longitudinal study.

Setting: A 21-week cognitive rehabilitation programme and a cognitive programme with varying length in two different Dutch rehabilitation centres.

Subjects: Forty-eight consecutive patients with acquired brain injury enrolled during a 15-month period.

Interventions: Cognitive rehabilitation programme.

Main measure: Goal attainment scaling; the number of goals was counted; time to set goals was recorded; the number of different domains in which goals were set was counted; goal attainment scaling score was calculated at baseline, one week after the end of the cognitive rehabilitation programme and at six months follow-up; clinical experiences that could be useful for both clinical and research practice were recorded.

Results: The mean (SD) age of the patients was 46.1 (10.7) years; 29 (60%) were male; 186 goals were set with a mean (SD) number of 4 (1) goals per patient. It was possible to set at least three realistic goals per patient within 30 minutes. Most goals were set in the cognitive domain (i.e. memory and attention), followed by the behavioural domain (i.e. fatigue and aggression).

Conclusion: It proved possible to set three goals within an acceptable time-frame, to involve patients in the goal-setting procedure, to set realistic goals, and to set goals within relevant domains. Based on clinical experiences, goal attainment scaling is less feasible for research when patients lack insight, or suffer from comorbidity or mood problems.

Passive movement therapy in patients with moderate to severe paratonia; study protocol of a randomised clinical trial (ISRCTN43069940)

BACKGROUND

Paratonia, a form of hypertonia, is associated with loss of mobility and with the development of contractures especially in the late stages of the dementia. Passive movement therapy (PMT) currently is the main physiotherapeutic intervention. General doubt about the beneficial effects of this widely used therapy necessitates a randomised clinical trial (RCT) to study the efficacy of PMT on the severity of paratonia and on the improvement of daily care.

METHODS/DESIGN

A RCT with a 4-week follow-up period. Patients with dementia (according to the DSM-IV-TR Criteria) and moderate to severe paratonia are included in the study after proxy consent. By means of computerised and concealed block randomisation (block-size of 4) patients are included in one of two groups. The first group receives PMT, the second group receives usual care without PMT. PMT is given according to a protocol by physical therapist three times a week for four weeks in a row. The severity of paratonia (Modified Ashworth scale), the severity of the dementia (Global Deterioration Scale), the clinical improvement (Clinical Global Impressions), the difficulty in daily care (Patient Specific Complaints) and the experienced pain in daily care of the participant (PACSLAC-D) is assessed by assessors blind to treatment allocation at baseline, after 6 and 12 treatments. Success of the intervention is defined as a significant increase of decline on the modified Ashworth scale. The 'proportion of change' in two and four weeks time on this scale will be analysed. Also a multiple logistic regression analysis using declined/not declined criteria as dependent variable with correction for relevant confounders (e.g. stage of dementia, medication, co-morbidity) will be used.

DISCUSSION

This study is the first RCT of this size to gain further insight on the effect of passive movement therapy on the severity of paratonia.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN43069940.

Performance of the EQ-5D and the EQ-5D+C in elderly patients with cognitive impairments

Background

The EQ-5D is a reliable tool for measuring Health-Related Quality of Life (HRQoL). However, concern has been expressed that it may ignore elements of HRQoL, particularly cognition. In response to this concern, the EQ-5D has been extended with a cognitive dimension (EQ-5D+C). The aim of this study was to compare the performance of the EQ-5D and the EQ-5D+C in elderly patients with cognitive impairments by assessing their construct validity and responsiveness.

Methods

Data from the MEDICIE study (n = 196) were used, in which all questionnaires were rated by proxies.

Results

Regarding construct validity, we found similar correlations between the EQ-5D and the Mini Mental State Examination (MMSE) and between the EQ-5D+C and the MMSE. Furthermore, both the EQ-5D and the EQ-5D+C were responsive to changes in the MMSE, with the EQ-5D performing slightly better.

Conclusion

We conclude that the EQ-5D performs well for evaluating HRQoL in a population with cognitive impairments. Based on the results of this explorative study, it does not seem necessary to adjust the current classification system by adding a cognitive dimension. However, in order to compare both instruments regarding utility values, it is necessary to develop a new scoring algorithm for the EQ-5D+C by conducting a general population study. Considering the explorative nature of this study, it is recommended that more aspects of the validity of both the EQ-5D and the EQ-5D+C are explored in patients with cognitive impairments using a more tailored study design.

The seven minute screen: a neurocognitive screening test highly sensitive to various types of dementia

BACKGROUND

The seven minute screen (7MS) is a compilation of the temporal orientation test, enhanced cued recall, clock drawing, and verbal fluency. It has been shown to be useful for detecting Alzheimer's disease in a population of patients with memory complaints.

OBJECTIVE

To assess the predictive validity of the 7MS for various types of dementia, and the influence of depression and other psychiatric conditions on 7MS scores.

SETTING

Multicentre: secondary referral sites across the Netherlands.

SUBJECTS

542 patients with various types of dementia or depression, together with 45 healthy controls.

RESULTS

Alzheimer's disease was diagnosed in 177 patients, other types of dementia in 164. The sensitivity of the 7MS for Alzheimer's disease was 92.9% with a specificity of 93.5%. For other types of dementia the sensitivity was 89.4% and the specificity 93.5%. Cognitive abnormalities were found in 71% of the patients with depression (n = 31). The mean (SD) duration of administration of the 7MS was 12.4 (4.6) minutes, range 8 to 22, depending on dementia severity.

CONCLUSIONS

The 7MS is a useful screening tool for discriminating patients with dementia from cognitively intact patients. This not only applies to Alzheimer's disease but also to other types of dementia. Specificity with respect to depression was lower for the 7MS than for the MMSE.

Diagnosis of preclinical Alzheimer's disease in a clinical setting

INTRODUCTION

The aim of the study was to investigate whether the preclinical stage of Alzheimer's disease (AD) can be diagnosed in a clinical setting. To this end we investigated whether subjects with preclinical AD could be differentiated from subjects with nonprogressive mild cognitive impairment and from subjects with very mild AD-type dementia.

METHODS

Twenty-three subjects with preclinical AD, 44 subjects with nonprogressive mild cognitive impairment, and 25 subjects with very mild AD-type dementia were selected from a memory clinic population. Variables that were used to differentiate the groups were demographic variables, the Mini-Mental State Examination score, performance on cognitive tests, measures of functional impairment, and measures of noncognitive symptomatology.

RESULTS

Age and the scores for the delayed recall task could best discriminate between subjects with preclinical AD and subjects with nonprogressive mild cognitive impairment. The overall accuracy was 87%. The score on the Global Deterioration Scale and a measure of intelligence could best discriminate between subjects with preclinical AD and subjects with very mild AD-type dementia. The overall accuracy was 85%.

CONCLUSIONS

Subjects with preclinical AD can be distinguished from subjects with nonprogressive mild cognitive impairment and from subjects with very mild AD-type dementia. This means that preclinical AD is a diagnostic entity for which clinical criteria should be developed.

[Consensus on the concepts of cortical, subcortical and frontal dementia. Research by national and international dementia experts]

The level of agreement concerning the concepts cortical, subcortical and frontal dementia. The level of agreement between experts in the field of dementia concerning cortical, subcortical and frontal dementia was established. Nowadays these syndromes are implemented in clinical practice; the discussion about the validity and reliability of these concepts however has diminished. Forty-one national and international dementia experts of four disciplines completed a questionnaire, based on the cognitive section of the CAMDEXR. For each syndrome they marked whether the cognitive function mentioned was impaired or unimpaired in cortical, subcortical and frontal dementia. The level of agreement between experts was determined by use of a derivative of the kappa-coefficient. Cortical dementia was characterised by high levels of agreement between the experts. With an observed level of agreement of 0.76, experts reached the highest consensus about this syndrome. Less agreement was observed in the judgements of subcortical and frontal dementia, with observed levels of agreement of 0.64 and 0.67 respectively. No differences were found in the assessments of national and international experts, as well as between the participating disciplines. Apparently, the application of these syndromes in clinical practice is difficult. Because of this confusion the practical meaning is limited, and one may wonder wether these concepts must still be used in clinical practice.

The influence of soy-derived phosphatidylserine on cognition in age-associated memory impairment

Phosphatidylserine (PS) is a phospholipid widely sold as a nutritional supplement. PS has been claimed to enhance neuronal membrane function and hence cognitive function, especially in the elderly. We report the results of a clinical trial of soybean-derived PS (S-PS) in aging subjects with memory complaints. Subjects were 120 elderly (> 57 years) of both sexes who fulfilled the more stringent criteria for age-associated memory impairment (AAMI); some also fulfilled the criteria for age-associated cognitive decline. Subjects were allocated at random to one of the three treatment groups: placebo, 300mg S-PS daily, or 600mg S-PS daily. Assessments were carried out at baseline, after 6 and 12 weeks of treatment, and after a wash-out period of 3 weeks. Tests of learning and memory, choice reaction time, planning and attentional functions were administered at each assessment. Delayed recall and recognition of a previously learned word list comprised the primary outcome measures. No significant differences were found in any of the outcome variables between the treatment groups. There were also no significant interactions between treatment and 'severity of memory complaints'. In conclusion, a daily supplement of S-PS does not affect memory or other cognitive functions in older individuals with memory complaints.

[Successful treatment of depression in a Parkinson disease patient with bupropion]

A 70-year-old female patient with Parkinson's disease was admitted to hospital with a medication-resistant depression. Electroconvulsion therapy was considered indicated, but it was decided to try treatment with bupropion chloride first. This resulted in a quick and complete remission of depressive symptoms, without any negative effects on motor symptoms. Bupropion has a unique mechanism of action: inhibition of the presynaptic reuptake of dopamine in addition to noradrenergic activity. Furthermore, it lacks the negative adverse effects on the extrapiramidal symptoms, that may be a problem if other antidepressants are used in the treatment. Bupropion is useful as an antidepressant in specific patient groups, notably patients with Parkinson's disease.

The validity of the Beck Depression Inventory as a screening and diagnostic instrument for depression in patients with Parkinson's disease

PURPOSE

To evaluate the validity of the Beck Depression Inventory (BDI) as a screening and diagnostic scale for depression in Parkinson's disease (PD).

PATIENTS AND METHODS

Fifty-three nondemented patients with PD were diagnosed according to a standardized protocol consisting of the depression module of the Structured Clinical Interview for DSM axis I disorders (SCID) and the BDI. A "receiver operating characteristics" (ROC) curve was obtained and the sensitivity, specificity, positive and negative predictive values (PPV and NPV, respectively) were calculated for different cut-off points of the BDI.

RESULTS

Maximum discrimination was obtained with a cut-off score of 13/14. High sensitivity and NPV were obtained with cut-off scores of 8/9 or lower; a high specificity and PPV were obtained with cut-off scores of 16/17 or higher. The area under the ROC curve was 85.67%.

CONCLUSION

A single cut-off score on the BDI to distinguish nondepressed from depressed patients with PD is not feasible. If one accepts the low specificity, then the BDI can be used as a valid screening instrument for depression in PD with a cut-off of 8/9. With a cut-off score of 16/17, it can be used as a diagnostic scale, at the cost of a low sensitivity. The use of diagnostic criteria for depression remains necessary.

The validity of the Hamilton and Montgomery-Asberg depression rating scales as screening and diagnostic tools for depression in Parkinson's disease

The concurrent validity of the Hamilton Rating Scale for Depression (HAMD-17) and the Montgomery-Asberg Depression Rating Scale (MADRS) against the DSM-IV diagnosis 'depressive disorder' was assessed in patients with Parkinson's disease (PD). Sixty-three non-demented Parkinson's Disease (PD) patients who attended the outpatient department of an academic hospital were diagnosed according to a standardised research protocol. This protocol consisted of the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) to establish the presence or absence of 'depressive disorder' according to the DSM-IV criteria, as well as the HAMD-17 and the MADRS. Receiver Operating Characteristics curves (ROC curves) were obtained and the positive and negative predictive values (PPV, NPV) were calculated for different cut-off scores. Maximum discrimination between depressed and non-depressed patients was reached at a cut-off score of 13/14 for the HAMD-17, and at 14/15 for the MADRS. At lower cut-offs, like 11/12 for the HAMD-17 and 14/15 for the MADRS, the high sensitivity and NPV make these scales good screening instruments. At higher cut-offs, such as 16/17 for the HAMD-17 and 17/18 for the MADRS, the high specificity and PPV make these instruments good diagnostic instruments. The diagnostics performance of the HAMD-17 is slightly better than that of the MADRS. This study shows that it is justified to use the HAMD-17 and the MADRS to measure depressive symptoms in both non-depressed and depressed PD patients, to diagnose depressive disorder in PD, and to dichotomize patient samples into depressed and non-depressed groups.

Distinction between preclinical Alzheimer's disease and depression

OBJECTIVE

To assess the prevalence of depression in subjects with preclinical Alzheimer's disease (AD) and to investigate the possibility of differentiating subjects with preclinical AD and depression from subjects with depression-related cognitive impairment.

DESIGN

A prospective, observational cohort study.

SETTING

An outpatient memory clinic of a university-affiliated hospital.

PARTICIPANTS

Nondemented subjects with cognitive impairment older than 55 years (n = 111) without neurological or somatic causes for the cognitive impairment.

MEASUREMENTS

At baseline, data were collected on patient characteristics, the severity of depression, and cognitive functioning. The course of the cognitive impairment and the presence of dementia were assessed after 2 and 5 years.

RESULTS

Twenty-five subjects had preclinical dementia with Alzheimer's type dementia at follow-up. Sixty percent of these subjects (n = 15) were depressed at baseline. Subjects with depression and preclinical AD had at baseline a poorer performance on the cognitive tasks and were older than the subjects with depression-related cognitive impairment. Logistic regression with backward step selection selected age and memory performance as the best predictors for Alzheimer's type dementia in the depressed subjects. The specificity of these predictors for the diagnosis of future Alzheimer's type dementia in depressed subjects was 94%, sensitivity was 90%, positive predictive value was 90%, and negative predictive value was 94%.

CONCLUSIONS

Depression is common in preclinical AD. Depressed subjects with preclinical AD can be accurately differentiated from subjects with depression-related cognitive impairment by age and the severity of the memory impairment. Research that aims to investigate preclinical AD should not exclude a priori subjects with depression inasmuch as preclinical AD is often accompanied by depression.

Course of objective memory impairment in non-demented subjects attending a memory clinic and predictors of outcome

The aim of the study was to investigate the course of objective memory impairment in non-demented subjects who attended a memory clinic and to test predictors of outcome. Non-demented subjects (N=74) were included when they were older than 40 years and had a baseline score on the delayed recall of a word learning test below the tenth percentile. Subjects with memory impairment due to known somatic or neurological causes were excluded. The subjects were reassessed after 2 and 5 years. At the 5-year follow-up, 42% of the subjects had no memory impairment, 19% of the subjects had memory impairment without dementia, and 39% of the subjects had Alzheimer type dementia (AD). Predictors at baseline of reversible memory impairment in a multivariate analysis were age, scores on the MMSE and delayed recall, and the degree of functional impairment. Predictors at baseline of AD in a multivariate analysis were age and the score on the MMSE. The apolipoprotein E genotype and the presence of depression at baseline were not predictors of outcome. The positive predictive value was 72% for reversible memory impairment and 81% for AD. Memory impairment is often reversible and therefore its presence alone is not sufficient to consider subjects as preclinically demented. Predictive accuracy can be increased by including simple measures such as age, the scores on the MMSE and delayed recall, and the degree of functional impairment.

Brain correlates of memory dysfunction in alcoholic Korsakoff's syndrome

OBJECTIVES

To investigate the relation between anterograde amnesia and atrophy of brain structures involved in memory processing in alcoholic Korsakoff's syndrome.

METHODS

The volume of brain structures involved in memory processing was measured with MRI from 13 subjects with Korsakoff's syndrome, 13 subjects with chronic alcoholism without Korsakoff's syndrome, and 13 control subjects. The brain structures analysed were the hippocampus, the parahippocampal gyrus, the mamillary bodies, the third ventricle, and the thalamus. Brain volumes were correlated with the delayed recall of a verbal learning test.

RESULTS

Compared with subjects with chronic alcoholism and control subjects, subjects with Korsakoff's syndrome had a reduced volume of the hippocampus, the mamillary bodies, and the thalamus, and enlargement of the third ventricle. The impairment of delayed recall correlated with the volume of the third ventricle (r=-0.55, p=0.05) in the Korsakoff group.

CONCLUSIONS

Anterograde amnesia in alcoholic Korsakoff's syndrome is associated with atrophy of the nuclei in the midline of the thalamus, but not with atrophy of the mamillary bodies, the hippocampus, or the parahippocampal gyrus.

Medial temporal lobe atrophy and memory dysfunction as predictors for dementia in subjects with mild cognitive impairment

To determine whether the medial temporal lobe is atrophic in subjects with mild cognitive impairment, and whether atrophy of this structure is a better predictor of dementia than memory dysfunction. Forty-five noninstitutionalized subjects aged 65-85 years were randomly selected from a population based study to obtain a sample with Alzheimer's disease (AD; n = 7), and a clinically nondemented sample (n = 38). Twenty of the latter subjects displayed some cognitive impairment and fulfilled CAMDEX criteria for "minimal dementia." Coronal T1-weighted magnetic resonance imaging was used to visualize the medial temporal lobe. The volume of the parahippocampal gyrus and hippocampus was measured, and medial temporal lobe atrophy was assessed qualitatively. The memory subscore from the CAMCOG was used as a measure of memory functioning. The follow-up period was 3 years. Nine subjects who were diagnosed as being minimally demented at baseline met the criteria for AD during follow-up. At baseline the volume of the parahippocampal gyrus of these subjects was smaller than that of the other subjects with minimal dementia. The memory score was the best predictor of clinical outcome. All medial temporal lobe measures increased the accuracy of prediction compared with only the memory score, by reducing the number of false-negative classifications of dementia. Severe medial temporal lobe atrophy is present even in some subjects with mild cognitive impairment and is an indicator of subsequent AD. The absence of medial temporal lobe atrophy, however, does not exclude the development of dementia. In the majority of subjects memory impairment was a better predictor of dementia than atrophy of the medial temporal lobe. The combination of the two increased predictive accuracy. Nondemented subjects with severe atrophy of the medial temporal lobe could be enrolled in drug trials aimed at slowing the progression of AD.

[Cholinesterase inhibitors for Alzheimer disease: preliminary recommendations for treatment. Dutch Society for Psychiatry, Section of Geriatric Psychiatry]

Several cholinesterase inhibitors have recently become available for Alzheimer's disease. To reach consensus about their relevance and use in daily practice, a meeting with clinical experts was organised by the section of Geriatric Psychiatry of the Dutch Society for Psychiatry. So far, available drugs have only very modest effects on cognitive functioning and clinical impression, compared with placebo. The question whether these effects are clinically relevant cannot be answered yet. Awaiting the results of further studies, it was decided not to use cholinesterase inhibitors on a routine basis but to limit prescription of these drugs to research setting or under well-controlled conditions with regard to diagnosis and evaluation. Furthermore, prescription must be limited to mild or moderately severe dementia caused by 'probable Alzheimer's disease'. Proper evaluation in the individual patient is still an unresolved problem. Therefore, n = I protocols are to be designed. These should include the use of appropriate and standardised instruments measuring cognitive functions, behavioural functions and activities of daily life. The skills and experience required will be available in specialised and multidisciplinary units for dementia. Pharmaceutical treatment for Alzheimer's disease must be integrated with all other available forms of patient care.

A controlled study into the effects of psychoeducation for patients with cognitive disturbances

The therapeutic results of an experimental neuropsychological rehabilitation program, Function-Oriented Guidance (FOG), for patients with mild cognitive disturbances were examined and compared with a regular Function Training (FT) program. FOG is based on thorough evaluation of neuropsychological test results, psychoeducation, and individual counseling. Within the FOG group, but not the FT group, patients' worries decreased and their level of knowledge increased. The results imply that psychoeducation may be of therapeutic value in patients with cognitive disturbances because it improves the way they cope with their handicaps. Contrary to expectations, between-group analyses showed few differences between the programs. Nevertheless, it can be concluded that psychoeducation for cognitively disturbed patients can contribute to improving their quality of life. However, further research with more patients is necessary.

Selective serotonin reuptake inhibitors (SSRIs) in the treatment of elderly depressed patients: a qualitative analysis of the literature on their efficacy and side-effects

A qualitative analysis of studies on the efficacy and side-effects of selective serotonin reuptake inhibitors (SSRIs) for the treatment of elderly people with depression is presented. Only placebo-controlled or comparison studies of SSRI versus other antidepressants were included. The description and methodological quality of the analysed studies were important criteria in the outcome of the analysis. Quality was assessed by means of a blinded review approach. After excluding duplicate publications, 16 studies were analysed, of which six turned out to be of good quality. The results indicated that at the end of the treatment periods (4-8 weeks) all antidepressants were equally effective. Side-effects occurred less frequently with SSRIs than with tricyclics (TCAs), and different side-effect profiles were found. Significantly fewer SSRI-treated patients than TCA-treated patients dropped out both overall and due to side-effects.

Comparison of seven sets of criteria used for the diagnosis of vascular dementia

At least seven different sets of criteria are commonly used for the diagnosis of vascular dementia (VaD). These are the ischemic scales (IS) of Hachinski, Rosen and Loeb, the criteria from the DSM-III-R, those outlined by Erkinjuntti et al., the State of California Alzheimer's Disease Diagnostic and Treatment Centers (ADDTC) and the international workgroup of the American National Institute of Neurological Disorders and Stroke (NINDS) and the European "Association Internationale pour la Recherche et l'Enseignement en Neurosciences'. To investigate the differences and similarities of these criteria, we applied them to a sample of 124 demented patients from the Maastricht Memory Clinic. Only 8 patients were diagnosed as having VaD by all criteria. Depending on which criteria were used, the frequencies of VaD and Alzheimer's disease (AD) ranged from 6 to 32%, and from 48 to 56%, respectively. The IS of Hachinski and Rosen resulted in the highest frequencies of VaD, whereas the criteria of Erkinjuntti and those from the ADDTC and the NINDS workgroup yielded the lowest. The number of patients with VaD was reduced substantially when neuroradiological data and the temporal relationship between stroke and dementia were taken into consideration. We conclude that the seven sets of criteria cannot be regarded as interchangeable. Differences in the criteria for VaD and AD may be an overlooked source of interstudy variance

Cognitive impairment in elderly people. Predisposing factors and implications for experimental drug studies

The consequences for cognitive functioning of normal aging, depression and dementia are well known. However, the borderline between normal and pathological cognitive aging is less well understood. Recently, it has been found that it is important to differentiate between 'successful', 'usual' and pathological cognitive aging. This article reviews existing views on this borderline. Recently, it has been found that health-related factors, or biological life events, may determine the rate of cognitive aging. Various different, but similar, diagnostic descriptions of age-related cognitive dysfunction exist simultaneously: benign senescent forgetfulness, malignant senescent forgetfulness, age-associated memory impairment, age-consistent memory impairment, late-life forgetfulness, mild cognitive changes (subthreshold) and cognitive impairment disorders are some examples of different diagnostic categories. There are also various diagnostic tools to obtain these experimental diagnoses; for example, the Global Deterioration Scale, the Clinical Dementia Rating Scale and the Cambridge Mental Disorders of the Elderly Examination. A diagnosis is considered important for the early detection of dementia. Pharmacological treatments are still in the experimental stage. Improvement of cognitive function has particularly been studied in clinical trials with groups of patients with Alzheimer's disease as well as patient groups with age-associated memory impairment. Future strategies may orient more towards treating symptoms of cognitive dysfunction, probably also on the basis of diagnosis of health-related factors, in age-related cognitive decline and depression.

Problems of caregiving spouses of patients with dementia

Twenty-six caregiving spouses of patients with dementia in the Netherlands were interviewed to better understand their problems and needs. Special attention was paid to the information the caregivers received from their general practitioner. Nineteen caregivers indicated that they received little or no information about the disease and its possible consequences. Furthermore, they experienced many problems, because of the disease and the daily care they provided; eleven caregivers indicated a decrease in social contact, which resulted in further problems. Caregivers who sought professional help at an early stage experienced fewer problems in providing daily care. The results of this project suggest that in future health education policy special attention should be paid to the role of the general practitioner and to the importance of a caregiver's social network.

Primitive reflexes in Alzheimer's disease and vascular dementia

Data on the prevalence and clinical value of primitive reflexes (PRs) in dementia are controversial, mainly due to a lack of standardization of the methods by which these signs are elicited and scored. A standardized protocol was used to investigate eight PRs in 20 patients with Alzheimer's disease (AD), 20 patients with vascular dementia (VD), and 20 control subjects for each group. Both patient groups showed considerably more PRs than the control groups. The prevalence of PRs was related to the severity of dementia. No single reflex or combination of PR pathognomonic for dementia could be distinguished. The PR profile of AD and VD patients were similar.

Depression, insight, and personality changes in Alzheimer's disease and vascular dementia

Although it is generally believed that depression, retained insight, and preserved personality occur more frequently in vascular dementia than in Alzheimer's disease, there is little empiric evidence for this presumption. Most studies on this subject have been carried out with severely demented inpatients, and confounding factors such as age, sex, and severity of dementia have not been sufficiently taken into account. We compared 48 patients with relatively mild vascular dementia with 48 patients with Alzheimer's disease, matched for age, sex, and stage of dementia, to investigate if depression, lack of insight, and personality changes were related to the cause of dementia. The two groups did not differ regarding the incidence of major depression, the mean depression score, the awareness score, or the sum of scores on the items of the Blessed Dementia Scale concerning personality changes. We conclude that depression, lack of insight, and personality changes do not favor an etiology of vascular dementia over that of Alzheimer's disease. The present findings underscore the notion that the severity of the dementia should be considered in studies on the differences between vascular dementia and Alzheimer's disease.

Treatment of depression in Parkinson's disease: a meta-analysis

Despite a 40% prevalence of depression in idiopathic Parkinson's disease (PD), an extensive literature search found only 12 controlled studies of treatment efficacy. A meta-analysis of these was performed in pursuit of guidelines for pharmacological treatment. Articles were scored on a scale from 0 to 100 on a specially adapted list of methodological criteria. Only 4 articles scored more than 50 points, and these generally did not use depression rating scales. Thus, there are virtually no empirical data on the treatment of depression in PD. Further studies are urgently needed, both for the sake of patient care and to gain a better understanding of the pathophysiological mechanisms underlying depression in PD and the interrelation between depression and cognitive decline.

Public education about normal forgetfulness and dementia: importance and effects

In the Netherlands considerable attention has been given to dementia, but hardly any is paid to normal forgetfulness. Two information meetings about the differences between normal forgetfulness and dementia were organized in order to meet current information needs. Evaluation of those meetings gave more insight into the characteristics of people who are worried about their diminishing memory and provided the opportunity of measuring changes in knowledge and anxiety. Almost 50% of the 450 participants indicated that they were worried about their memory; 66% of these people reported being more or less reassured afterwards. Although the level of knowledge increased, no correlation was found between increased knowledge and decreased anxiety. Because of people's anxiety about possible dementia, it is important to provide the general public with more information about this subject. More research, with a control group, is necessary to draw conclusions about the effectiveness of health education in this area.