Tackling The Challenge Of Opioid Use And Abuse And Treatment Of Chronic Pain Management

Introduction/Objective

Deaths from opioid overdose increased 12% from 2016 to 2017. This major economic burden cost roughly $78.5 billion in the US. This steep increase in drug overdose deaths can be attributed to increased synthetic opioid abuse. To better understand and reduce opioid abuse amongst patients at Henry Ford Health System, Detroit MI, we sought to collaborate with physicians to manage prescribing, interpret test results, improve patient care, and deliver more value.

Primary Aim: To create a directed pain panel for ordering and interpreting pain management drugs to help providers to better manage patients and to assess compliance from test ordering history to serve patients safely and effectively.

Secondary Aim: To streamline the process of prescribing pain medications and to create a patient centered approach to treat chronic non-cancer patients who actually need opioids, to minimize the risk of abuse, diversion and addiction among patients.

Methods

Plan Do Check Act (PDCA) cycles of process improvement were used to achieve our two aims. In the first cycle, a drug screen-ordering guide was developed to facilitate screening (qualitative) and confirmation (quantitative) ordering practices. As part of this, providers prescribing for chronic pain patients were advised to use drugs of abuse panel rather than our emergency drug screen. In the second cycle, a directed pain panel (DPP) was introduced with reflex to confirmation testing. The DPP led to discovery of unexpected fentanyl positives, which were further investigated.

Results

A survey was conducted to investigate provider-ordering practices, which showed that use of the new drugs of abuse panel rose from 57% to 77%. The DPP was accepted by ~60% of physicians and was frequently reordered in follow-up. Analysis of unexpected fentanyl positivity revealed 30% true positivity, thus identifying unknown patient use. A future PDCA cycle is focused on developing, implementing, and measuring the customer value of a laboratory generated interpretive opioid results report at 5 similar organizations with a goal to assist with test selection and simplify provider interpretation of results.

Conclusion

A future PDCA cycle is focused on developing, implementing, and measuring the customer value of a laboratory generated interpretive opioid results report at 5 similar organizations with a goal to assist with test selection and simplify provider interpretation of results.

Is the relationship between syndromes of depression and dementia temporal? The MRC-ALPHA and Hefei-China studies

BACKGROUND

Recent studies have shown a temporal association between depressive symptoms and cognitive decline. However, the relationship between syndromes of depression and dementia is unknown.

METHOD

A total of 1736 people aged > or = 65 years in China and 5222 older people in the UK were interviewed using the Geriatric Mental State Examination (GMS) and reinterviewed at follow-up. Five levels of syndromes of depression and dementia were diagnosed using the Automated Geriatric Examination for Computer Assisted Taxonomy (AGECAT).

RESULTS

Although there were fewer depressive syndromes in Chinese than British participants, both populations showed a similarly high level of syndromes of dementia (organic disorder) (20% for women, 14% for men). There was a significant cross-sectional correlation between syndrome levels of depression and dementia (correlation coefficients: 0.141-0.248 for Chinese, 0.168-0.248 for British). This was maintained for different age, gender and people with and without cardiovascular disease (CVD). The relationship between syndromes of baseline depression and follow-up dementia was less substantial: the correlation coefficient was 0.075 [95% confidence interval (CI) 0.021-0.128] for the Chinese sample at the 1-year follow-up, and 0.093 (95% CI 0.061-0.125) for the British at the 2-year follow-up and 0.093 (95% CI 0.049-0.130) at the 4-year follow-up. This relationship disappeared in participants without baseline organic syndromes. In a multiple adjusted logistic regression analysis, an increased risk of organic syndromes seemed to be associated with baseline, mainly in the highest level of, depressive syndromes.

CONCLUSIONS

The relationship between syndromes of depression and dementia might be temporal. The lack of an obvious dose-response relationship between baseline depressive syndromes and follow-up dementia syndromes suggests that the causal relationship between depression and dementia needs further investigation.

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.

Religion as a cross-cultural determinant of depression in elderly Europeans: results from the EURODEP collaboration

BACKGROUND

The protective effects of religion against late life depression may depend on the broader sociocultural environment. This paper examines whether the prevailing religious climate is related to cross-cultural differences of depression in elderly Europeans.

METHODS

Two approaches were employed, using data from the EURODEP collaboration. First, associations were studied between church-attendance, religious denomination and depression at the syndrome level for six EURODEP study centres (five countries, N = 8398). Secondly, ecological associations were computed by multi-level analysis between national estimates of religious climate, derived from the European Value Survey and depressive symptoms, for the pooled dataset of 13 EURODEP study centres (11 countries, N = 17,739).

RESULTS

In the first study, depression rates were lower among regular church-attenders, most prominently among Roman Catholics. In the second study, fewer depressive symptoms were found among the female elderly in countries, generally Roman Catholic, with high rates of regular church-attendance. Higher levels of depressive symptoms were found among the male elderly in Protestant countries.

CONCLUSIONS

Religious practice is associated with less depression in elderly Europeans, both on the individual and the national level. Religious practice, especially when it is embedded within a traditional value-orientation, may facilitate coping with adversity in later life.

Group office visits change dietary habits of patients with coronary artery disease-the dietary intervention and evaluation trial (D.I.E.T.)

BACKGROUND

We evaluated the effectiveness of a low-cost group visit intervention for changing the dietary intake and lipid levels of patients with known coronary artery disease (CAD).

METHODS

We performed a controlled random group assignment trial in 4 community outpatient clinics. The Dietary Intervention and Evaluation Trial randomized 97 patients with CAD to either a control group that followed the National Cholesterol Education Program's Step II-III diet plan (n=48) or an experimental group that received meal plans, recipes, and nutritional information during monthly group office sessions (n=49). Both groups received lipid-lowering medications and were followed-up over 12 months. We assessed dietary intake, fasting lipid profiles, hemoglobin A1C levels, and per member per month (PMPM) expense data.

RESULTS

Food frequency data showed that eating fruits and vegetables and cooking with monounsaturated fat increased significantly in the experimental group compared with the control group at 1 year (P=.0072; P=.0001; P=.0004). The total PMPM expenses decreased for both groups (38% for the experimental group and 10% for the control group), but the cost difference was statistically nonsignificant (P=.2975). Both groups noted low-density lipoprotein reductions, significant only in the experimental group (P=.0035).

CONCLUSIONS

Our study suggests that using group office visits for patients with CAD was an effective method for helping subjects make dietary changes and for improving lipid levels. Patients with known CAD and elevated lipid levels were willing to make significant lifestyle changes when offered a program that emphasizes healthy foods in a group visit format.

Prognosis with dementia in Europe: A collaborative study of population-based cohorts. Neurologic Diseases in the Elderly Research Group

The effect of dementia on time to death and institutionalization in elderly populations is of importance to resource planning, as well as to patients and their carers. The authors report a collaborative reanalysis of nine population-based studies conducted in Europe to compare dementia cases and noncases in risk of and time to death and to institutionalization. Prevalent and incident cases were more likely than noncases to reside in an institution at baseline and were more likely to enter institutional care. Prevalent cases also had over twice the risk of death compared to noncases and survival for men with dementia was consistently lower than that for women with dementia of the same age group.

Prevalence of dementia and major subtypes in Europe: A collaborative study of population-based cohorts. Neurologic Diseases in the Elderly Research Group

The last comparison of prevalence figures of dementia across European studies was 10 years ago. Using studies conducted in the 1990s, the authors compare the age- and sex-specific prevalence of dementia, AD, and vascular dementia (VaD) across European population-based studies of persons 65 years and older. Data from these studies were also pooled to obtain stable estimates of age- and sex-specific prevalence. A total of 2346 cases of mild to severe dementia were identified in 11 cohorts. Age-standardized prevalence was 6.4% for dementia (all causes), 4.4% for AD, and 1.6% for VaD. The prevalence of dementia increased continuously with age and was 0.8% in the group age 65 to 69 years and 28.5% at age 90 years and older. The corresponding figures for AD (53.7% of cases) were 0.6% and 22.2%, and for VaD (15.8% of cases), 0.3% and 5.2%. Variation of AD prevalence across studies was greatest for men. In the VaD subtype, a large variation across studies was observed, as well as a difference in prevalence between men and women that was age dependent. Dementia is more prevalent in women, and AD is the main contributor to the steep increase of prevalence with age.

Incidence of dementia and major subtypes in Europe: A collaborative study of population-based cohorts. Neurologic Diseases in the Elderly Research Group

The authors examined the association of incident dementia and subtypes with age, sex, and geographic area in Europe. Incidence data from eight population-based studies carried out in seven European countries were compared and pooled. The pooled data included 835 mild to severe dementia cases and 42,996 person-years of follow-up. In all studies a higher proportion of cases were diagnosed with AD (60 to 70% of all demented cases) than vascular dementia (VaD). The incidence of dementia and AD continued to increase with age up to age 85 years, after which rates increased in women but not men. There was a large variation in VaD incidence across studies. In the pooled analysis, the incidence rates increased with age without any substantial difference between men and women. Surprisingly, higher incidence rates of dementia and AD were found in the very old in northwest countries than in southern countries. This study confirms that AD is the most frequent dementing disorder in all ages, and that there is a higher incidence of dementia, specifically AD, in women than men among the very old. Finally, there may be regional differences in dementia incidence.

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.

Socio-economic deprivation and the prevalence and prediction of depression in older community residents. The MRC-ALPHA Study

BACKGROUND

The Townsend index is a measure of social deprivation. It can be applied to postal districts and has been employed in studies examining the ecological associations of mental illness.

AIMS

We examine the utility of the Townsend index in identifying older populations with a high prevalence and risk of developing depression.

METHOD

The study was carried out in the context of a cohort study of an age- and gender-stratified sample of 5222 community residents aged 65 years and over. Subjects were interviewed at intervals of two years. The relationships between Townsend score and psychiatric diagnoses (in particular, depression) were examined.

RESULTS

High Townsend scores were associated with increased prevalence and incidence of depression and prevalence of organic psychiatric illness.

CONCLUSIONS

The Townsend index can be used to prioritize psychiatric and primary care resources so as to cater for older populations likely to suffer from depression and organic psychiatric conditions.

Natural history of pharmacotherapy of older depressed community residents. The MRC-ALPHA Study

BACKGROUND

Depression in older people is common and has a high mortality, but effective treatments exist.

AIMS

To describe drug prescribing in older community residents in relation to depression status.

METHOD

The MRC-ALPHA community cohort aged 65 and over were interviewed using the Geriatric Mental State examination drug data collected at index interview and at two and four years.

RESULTS

Antidepressants were used by 10.9% of the depressed population. Benzodiazepines were used frequently. Of the antidepressant users, 59.6% took low-dose antidepressants for two years, had a poor outcome and few drug changes.

CONCLUSIONS

Trends of increasing antidepressant use have cost implications for primary care groups. Benzodiazepines may be mis-prescribed for treatment of depressive symptoms. Antidepressant users have poor outcome and follow-up.

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.

A meta-analysis of epidemiological studies in depression of older people in the People's Republic of China

BACKGROUND

There has been little information about depression in Chinese elderly people. In order to investigate whether or not there is an excess of depression among the Chinese elderly, we have performed a meta-analysis of the published epidemiological studies.

METHODS

Papers published in the literature from The People's Republic of China included in the Chinese medical databases were obtained. Some additional papers collected from other sources were also included. The fixed/random effects model and Poisson model were employed for data analysis.

RESULTS

There were 10 cross-sectional studies (23 samples divided according to men/women and urban/rural subjects) giving sufficient prevalence data on depression (13 565 subjects) or depressive mood (8476 subjects). The pooled prevalence of depression was 3.86% (95%CI 3.37-4.42%), while that of depressive mood was 14.81% (14.20-15.64%). The risk of depression in the rural communities (5.07%, 3.61-7.13%) was higher than in the urban (2.61%, 2.22-3.08%). The same trends were observed for depressive mood. The patterns of risk factors were similar to those in western countries.

CONCLUSIONS

Chinese tradition and culture may be explanatory factors for the low prevalence, provided the methodological issues have not seriously biased the results.

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.

Depression of older age. Origins of the study

BACKGROUND

The EURODEP collaboration was formed to take advantage of existing studies of random community samples of older people in Europe, using GMS-AGECAT for case identification and diagnosis. Later, other centres joined, and the EURO-D scale was developed to harmonise the different methods used with the GMS. Previous studies had revealed different levels of depression in Europe but had been confounded by the use of unreconcilable methods. These studies attempt to overcome this problem.

AIMS

To introduce the first set of publications from the EURODEP collaboration.

METHOD, RESULTS AND CONCLUSIONS

Presented in five accompanying papers (pp. 307-345, this issue).

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.

Development of the EURO-D scale--a European, Union initiative to compare symptoms of depression in 14 European centres

BACKGROUND

In an 11-country European collaboration, 14 population-based surveys included 21,724 subjects aged > or = 65 years. Most participating centres used the Geriatric Mental State (GMS), but other measures were also used.

AIMS

To derive from these instruments a common depression symptoms scale, the EURO-D, to allow comparison of risk factor profiles between centres.

METHOD

Common items were identified from the instruments. Algorithms for fitting items to GMS were derived by observation of item correspondence or expert opinion. The resulting 12-item scale was checked for internal consistency, criterion validity and uniformity of factor-analytic profile.

RESULTS

The EURO-D is internally consistent, capturing the essence of its parent instrument. A two-factor solution seemed appropriate: depression, tearfulness and wishing to die loaded on the first factor (affective suffering), and loss of interest, poor concentration and lack of enjoyment on the second (motivation).

CONCLUSIONS

The EURO-D scale should permit valid comparison of risk-factor associations between centres, even if between-centre variation remains difficult to attribute.

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.

Review of community prevalence of depression in later life

BACKGROUND

Despite considerable interest, there is no consensus regarding the prevalence of depression in later life.

AIMS

To assess the prevalence of late-life depression in the community.

METHOD

A systematic review of community-based studies of the prevalence of depression in later life (55+). Literature was analysed by level of caseness at which depression was defined and measured.

RESULTS

Thirty-four studies eligible for inclusion were found. The reported prevalence rates vary enormously (0.4-35%). Arranged according to level of caseness, major depression is relatively rare among the elderly (weighted average prevalence 1.8%), minor depression is more common (weighted average prevalence 9.8%), while all depressive syndromes deemed clinically relevant yield an average prevalence of 13.5%. There is consistent evidence for higher prevalence rates for women and among older people living under adverse socio-economic circumstances.

CONCLUSIONS

Depression is common in later life. Methodological differences between studies preclude firm conclusions about cross-cultural and geographical variation. Improving the comparability of epidemiological research constitutes an important step forward.

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

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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.

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.

Extent and appropriateness of benzodiazepine use. Results from an elderly urban community

BACKGROUND

We sought to determine the extent and appropriateness of benzodiazepine use in an elderly community, by measuring prevalence and incidence of benzodiazepines and examining mental health status as a predictor of benzodiazepine use.

METHOD

Data were collected from two longitudinal studies of people from the same community, sampled in 1982-1983 and again in 1989-1991.

RESULTS

Benzodiazepine prevalence did not decrease during the period under study, but there was a significant reduction in anxiolytic use. Prevalence of benzodiazepines in women in twice that in men, and incidence of hypnotics is slightly higher in women. Prevalence and incidence of hypnotics are strongly associated with increasing age. There were high proportions of long-term users (61 and 70%), and continued use was high (52%) among new users. A large proportion of benzodiazepine use was by those who were concurrently depressed. Similarly, anxiety predicted both current and subsequent use of hypnotics.

CONCLUSIONS

Many older people still use benzodiazepines, contrary to official guidelines with regard to their mental health. Our findings add to the weight of opinion that persistent and long-term use should be discouraged.

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.

Recruitment issues in school-based research: lessons learned from the High 5 Alabama Project

School-based research requires a multi-level recruitment process to ensure an adequate sample. This article describes the High 5 Alabama recruitment experience at four levels; district, school, classroom and individual. One hundred percent of 28 schools across three districts and 108 classroom teachers contacted agreed to participate. Moderate success (69%) at the individual level, which required active parental consent for the student and parent to participate, resulted in 1,698 student/parent participants. An examination of differences between participants and nonparticipants revealed under-representation of a subsample of the population in the project sample. Suggestions obtained from project staff and teachers intended to enhance future school-based recruitment strategies include enlistment of a district advocate; meeting with teachers to solicit support; using incentives with students and teachers; direct contact with parents; having teachers keep rosters of students returning consent forms; and tailoring recruitment strategies for specific subpopulations.

Prevalence of dementia and depression among elderly people in black and ethnic minorities

BACKGROUND

This study was designed to identify all elderly people of ethnic minorities living in a defined geographical area in inner-city Liverpool and to identify psychiatric morbidity and barriers to use of services. This paper reports the prevalence of dementia and depression.

METHOD

A survey of the community was carried out using the Geriatric Mental State Examination, AGECAT and ethnically matched interviewers. The sampling frame consisted of Family Health Services Authority lists as a basis, with additional information from community lists, 'snow-balling' and a door-to-door survey.

RESULTS

418 people were interviewed, with a high percentage (55%) of young elderly (65-74) men. The prevalence of dementia ranged from 2 to 9% and of depression from 5 to 19%, and there were no significant differences in levels between English-speaking ethnic groups and the indigenous population. Higher levels of dementia were found among non-English-speaking groups.

CONCLUSIONS

A complete enumeration of the elderly in ethnic minority groups is best achieved by using several different methods. Diagnosis of dementia may be misleading among those who do not speak the dominant language.

Repeated cocaine administration reduces bradykinin-induced dilation of pial arterioles

Using the acute cranial window technique in rabbits under surgical anesthesia, we tested the vasoactivity of acetylcholine (ACh, 10(-8)-10(-5) M), bradykinin (BK, 10(-8)-10(-5) M), and asphyxia (10% O2, 9% CO2, balance N2) after subchronic pretreatment with cocaine. After repeated administration of cocaine (20 mg.kg-1.day-1 sc x 7 days), the BK-induced dilation of pial arterioles was reduced by 51%. Previous work showed that BK produces dilation of pial arterioles by a cyclooxygenase-dependent oxygen radical-mediated mechanism and that in rabbits the BK-induced dilation is dependent on both vascular and nonvascular cyclooxygenase. Selective blockade of vascular cyclooxygenase, in addition to cocaine treatment, did not produce any greater inhibition of the BK-induced dilation. The dilation in response to ACh and asphyxia was unaltered by cocaine. Levels of cerebrospinal fluid prostaglandins suggest cocaine pretreatment may inhibit cerebral vascular prostaglandin production. Together, cerebrospinal fluid prostaglandin and vasoreactivity data indicate cocaine pretreatment selectively inhibits the vascular cyclooxygenase-dependent mechanism mediating the BK-induced dilation. This decreased response to BK in cocaine-treated rabbits may result from decreased oxygen radical production concomitant with decreased vascular prostaglandin production. Alternatively, oxygen radical scavenging may be increased after cocaine treatment. We speculate that cocaine-induced alterations in cerebrovascular function and metabolism may be related to the increased incidence of stroke reported to occur in human cocaine users.

Long-term effects of cognitive-behavioural therapy and lithium therapy on depression in the elderly

BACKGROUND

We examine the effects of cognitive-behavioural therapy (CBT) as an adjuvant to acute physical treatment and lithium maintenance therapy in reducing depression severity over a follow-up year in elderly depressed patients.

METHOD

The study consists of three phases. During the acute treatment and continuation phase, 17 of 31 patients received CBT as an adjuvant to treatment as usual. During the maintenance phase of 1 year, subjects were entered into a double-blind, placebo-controlled study of low-dose lithium therapy.

RESULTS

Receiving adjuvant CBT significantly reduced patients' scores on the Hamilton Rating Scale for Depression during the follow-up year (repeated measures analyses of variance; P = 0.007). No significant differences were found between lithium and placebo maintenance therapy.

CONCLUSIONS

CBT can be adapted as an adjuvant therapy in the treatment of severely depressed elderly patients and reduces depression severity during follow-up. The prophylactic failure of long-term lithium therapy may be explained through poor compliance.

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.

Endothelial and nonendothelial cyclooxygenase mediate rabbit pial arteriole dilation by bradykinin

Aspirin (acetylsalicylic acid, ASA) was administered to rabbits in an attempt to inhibit selectively endothelial cyclooxygenase activity and therefore to determine its role in bradykinin-induced radical-mediated dilation of cerebral arterioles. With the use of the cranial window technique in anesthetized rabbits, pial arteriolar diameters were recorded in response to topically applied bradykinin, acetylcholine, and ventilation with 10% O2-9% CO2 gas mixture. Prostaglandins were measured in isolated cerebral microvessels and cerebrospinal fluid (CSF) using radioimmunoassay. Microvessel prostaglandin production was reduced significantly by 90 mg/kg i.v. ASA, whereas acetylcholine-stimulated increases of CSF prostaglandins were not similarly affected. This treatment reduced bradykinin-induced dilation of pial arterioles by 47%. After concurrent 90 mg/kg i.v. ASA plus 300 microM ASA topically applied to the brain, stimulated increases of CSF prostaglandins were reduced by 79%, while bradykinin-induced dilation was reduced by 78%. ASA did not reduce the dilator activity of either acetylcholine or ventilation with 10% O2-9% CO2. Acetylcholine- but not bradykinin-induced dilation was reduced by NG-nitro-L-arginine methyl ester. These results indicate intravenous ASA produced a relatively selective inhibition of cerebral microvascular cyclooxygenase and partial inhibition of bradykinin-induced dilation. Further inhibition of dilation occurred following ASA administered both systemically and topically to the brain. This indicates two sources of cyclooxygenase, endothelial and nonendothelial, mediate the bradykinin-induced dilation of rabbit pial arterioles. Furthermore, systemic doses of ASA do not eliminate brain prostaglandin formation.

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.

Semi-structured depression scale sensitive to change with treatment for use in the elderly

The construction of a semi-structured interview depression scale that is sensitive to change for use in the elderly is described. Depression items from a well validated diagnostic instrument, the Geriatric Mental State Schedule (GMSS), were used as the core items in the development of the instrument. Improvement in depression in 80 elderly patients was independently assessed with two standard rating scales for depression, the Hamilton Rating Scale for Depression and the Beck Depression Inventory, and by an independent clinician's judgement before and after standard antidepressant treatment. Depression items that were sensitive to change were retained from the core items to form the new instrument. Results indicate that this scale is reliable and valid, shows better correlation with both the clinician's and the patient's judgement of improvement than the standard instruments, and is sparing of the rater's time.

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.

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.

Alzheimer's disease, other dementias, depression and pseudodementia: prevalence, incidence and three-year outcome in Liverpool

A group of 1070 community-living persons aged 65 and over was assessed using the GMS-AGECAT package and other interviews at years 0 and 3. Year 3 interviewers were 'blind' to the findings at year 0, and the prevalence of organic disorders and depression was very similar in both years. According to the results at year 3, minimum and maximum prevalence figures for dementia at year 0 were 2.4% and 3.8% for moderate to severe and 0.4% and 2.4% for mild or early cases, with a best estimate of 3.5% and 0.8%, or 4.3% overall, divided into: senile, Alzheimer's type 3.3%; vascular 0.7%; and alcohol-related 0.3%. The overall incidence of dementia, clinically confirmed by six-year follow-up, was 9.2/1000 per year (Alzheimer type 6.3, vascular 1.9, alcohol related 1.0). Three years later, 72.0% of those with depressive psychosis and 62.3% of those with depressive neurosis were either dead or had some kind of psychiatric illness. Nearly 60% of milder depressive cases (7.2% of the total sample) had either died or developed a chronic mental illness. The outcome of depressive pseudodementias is equivocal so far. Findings at year 3 provide validation of AGECAT computer diagnosis against outcome; organic and depression diagnoses are seen to have important implications for prognosis.

The natural history of neurotic disorder in an elderly urban population. Findings from the Liverpool longitudinal study of continuing health in the community

A random community sample of 1070 subjects aged 65 years and over was interviewed at home using the GMS-AGECAT package and followed up three years later. Neurotic symptoms were common, but symptoms sufficient to reach 'case' level were much less frequent. The overall prevalence of neurotic 'cases' was 2.4% in year 0 and 1.4% in year 3. The incidence was estimated as a minimum of 4.4 per 1000 per year over the age of 65. Women were more likely to be 'cases' than men but not 'subcases', and there was a general decline in prevalence with increasing age, particularly for 'subcases'. Anxiety was the commonest neurotic subtype. After three years, 'cases' were shown not to persist, but this did not reflect wellness. There was a tendency still to have some symptoms, but the predominant symptom appeared to change, suggesting a possible chronic neurotic disorder with changing presentation over time. Depressive symptoms were closely associated with this presentation, suggesting that depression may be an important and integral part of a general, changing neurotic disorder.

Geriatric Mental State-AGECAT: prevalence, incidence and long-term outcome of dementia and organic disorders in the Liverpool study of continuing health in the community

The GMS-AGECAT package was used in the initial assessment and 3-year follow-up of a random sample of 1,070 elderly people living in the community. A prevalence of 4.3% is found for dementia after confirmation of diagnoses by outcome at year 3. The overall incidence of dementia was 9.2/1,000 per year after partial adjustments for outcome of year 6. Incidence per year for sub-types of dementia were AD 6.3/1,000, vascular 1.9/1,000, and alcohol-related 1.0/1,000.

Alpha: the Liverpool MRC Study of the incidence of dementia and cognitive decline

The design and methods of this longitudinal study of dementia which is underway are described. An age- and sex-stratified random sample of 6,000 elderly community subjects are being re-assessed after a 2-year interval using the GMS-AGECAT package. Alpha forms part of the MRC funded UK multicentre incidence study and an international network of collaborative studies using comparable measures.

The prevalence of vascular dementia in Europe: facts and fragments from 1980-1990 studies. EURODEM-Prevalence Research Group

We selected, reanalyzed, and compared data from current prevalence studies of vascular dementia in Europe. Inclusion criteria were: dementia defined by the Diagnostic and Statistical Manual for Mental Disorders, edition 3, or equivalent criteria; case finding through direct individual examination; appropriate sample size; and inclusion of institutionalized persons. Mixed dementia was combined with vascular dementia. Of the 23 surveys of dementia considered, five fulfilled the inclusion criteria. Age-specific prevalence varied more widely for men than for women; differences were greater in older ages. The prevalence increased steeply with advancing age in all countries, and was generally higher in men; it declined over 15 years in the age class of 80 to 89 years in one Swedish population. Within populations, Alzheimer's disease was generally more common than vascular dementia. Unfortunately, prevalence studies of vascular dementia are limited in Europe and worldwide, and their comparison is impeded by the lack of common diagnostic criteria.

Frequency and distribution of Alzheimer's disease in Europe: a collaborative study of 1980-1990 prevalence findings. The EURODEM-Prevalence Research Group

We reanalyzed and compared current prevalence estimates of Alzheimer's disease in Europe. Studies characterized as follows qualified for comparison: dementia defined by the Diagnostic and Statistical Manual for Mental Disorders, 3rd edition, or equivalent criteria; Alzheimer's disease diagnosed by the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association or equivalent criteria; case-finding through direct individual examination; appropriate sample size; and inclusion of institutionalized persons. Of the 23 European surveys of dementia considered, six fulfilled the inclusion criteria. When age and sex were considered, there were no major geographic differences in the prevalence of Alzheimer's disease across Europe. Overall European prevalence (per 100 population) for the age groups 30 to 59, 60 to 69, 70 to 79, and 80 to 89 years was, respectively, 0.02, 0.3, 3.2, and 10.8. Prevalence increased exponentially with advancing age and, in some populations, was consistently higher in women. Prevalence remained stable over 15 years in one study.

The prevalence of dementia in Europe: a collaborative study of 1980-1990 findings. Eurodem Prevalence Research Group

To obtain age- and gender-specific estimates of the prevalence of dementia in Europe and to study differences in prevalence across countries, we pooled and re-analysed original data of prevalence studies of dementia carried out in some European countries between 1980 and 1990. The study followed these steps: census of existing datasets, collection of data in a standardized format, selection of datasets suitable for comparison, comparison of age and gender patterns. From the 23 datasets of European surveys considered, 12 were selected for comparison. Only population-based studies in which dementia was defined by DSM-III or equivalent criteria and in which all subjects were examined personally were included. Studies in which institutionalized subjects were not investigated were excluded. Age- and gender-specific prevalences were compared within and across studies and overall prevalences were computed. Although prevalence estimates differed across studies, the general age- and gender-distribution was similar for all studies. The overall European prevalences for the five-year age groups from 60 to 94 years, were 1.0, 1.4, 4.1, 5.7, 13.0, 21.6 and 32.2%, respectively. In subjects under 75 years the prevalence of dementia was slightly higher in men than in women; in those aged 75 years or over the prevalence was higher in women. The prevalence figures nearly doubled with every five years of increase in age.

Heavy drinking as a risk factor for depression and dementia in elderly men. Findings from the Liverpool longitudinal community study

A random community sample of subjects aged 65 and over was re-interviewed after three years by psychiatrists using the GMS and HAS. The relationship between drinking history and current psychiatric morbidity was examined. Men with a history of heavy drinking for five years or more at some time in their lives were found to have a greater than fivefold risk of suffering from a psychiatric disorder at the time of the interview. Among this group past alcohol consumption was significantly higher for those with a current psychiatric diagnosis compared with those who were well. This association between heavy alcohol consumption in earlier years and psychiatric morbidity in later life is not explained by current drinking habits.