Age modifies the association between apathy and recurrent falling in Dutch ambulant older persons with a high fall risk: Recurrent falling in Dutch outpatients, does apathy play a role?

Apathy, a common and disabling behavioural syndrome in older persons, has been associated with impaired physical performance and executive dysfunction. Both are fall risk factors and they share pathophysiological pathway. We cross-sectionally examined the association between apathy and recurrent falling (≥2 falls in the past 12 months) and number of falls in the past 12 months in 243 outpatients aged ≥65 years with ≥3 fall risk-factors visiting a fall-clinic after a fall. We calculated Odds Ratio's (ORs), Incidence Rate Ratio's (IRRs) and their 95% Confidential Intervals (CI95) using multivariable regression and negative binomial regression analyses. We adjusted for cognitive functioning, depression, the use of fall risk increasing drugs, visual impairment, urine incontinence, comorbidity, smoking, use of alcohol, body mass index (BMI), and the number of months between assessment of fall risk and of apathy. We assessed effect modification by age and gender. In our study, apathy was independently associated with recurrent falling in patients aged 65-75 years: OR 2.8 (CI95 1.0-7.7). Overall, patients with apathy experienced 1.46 times as many falls in the past 12 months compared to patients without apathy (IRR 1.46 (CI95 1.0-2.1). To conclude, in high fall-risk older outpatients, apathy was cross-sectionally associated with recurrent falling in patients aged 65-75 years and the number of falls. Apathy appeared to be especially relevant in relation to falling in this age group. Whether apathy predicts recurrent falling is yet to be determined.

Reliability of retrospective reports on childhood abuse and its determinants in older adults during a 6-year follow-up

Controversy exists concerning the reliability of retrospective self-reports on childhood abuse since this method might be subject to under- or overreporting. Until now, no studies have been done in older adults, although reasons for under- or overreporting could be even more prominent in this age group. In this first study in older adults, test-retest reliability of retrospective measurements on childhood abuse and the influence of age, cognitive functioning and depression on this test-retest reliability was investigated. A longitudinal cohort study, the Netherlands Study of Depression in Older persons (NESDO), obtained information on childhood abuse at baseline and at a 6-year follow-up interview. Our sample consisted of 277 adults (mean age 68.5 years at baseline) of which 118 (42.6%) reported childhood abuse at baseline. The largest proportion of the answers was consistent (yes-yes or no-no) for every type of childhood abuse, varying from 85.2 to 93.5%. Looking more closely, 'yes' answers were more fluctuating than 'no' answers. Sexual abuse was most reliably reported in two separate interviews. There was no significant effect of age nor cognition on the test-retest reliability. Only test-retest reliability of emotional neglect was significantly associated with depression diagnosis and depression severity at baseline. In conclusion, test-retest reliability of retrospective self-reports on childhood abuse seems moderate to good, but slightly dependent on the type of abuse. The test-retest reliability was influenced neither by age nor cognition, only reporting of emotional neglect was associated with depression state.

Inflammatory markers and cortisol parameters across depressive subtypes in an older cohort

BACKGROUND

There is growing evidence that inflammatory and cortisol dysregulation are underlying pathophysiological mechanisms in the aetiology of major depressive disorder, particularly in younger adults. However, findings of biological disturbances in late-life depression have been divergent, probably due to the even greater heterogeneity of depression in older adults with aging processes influencing biological factors. Using empirically derived subtypes may enable the identification of biological disturbances underlying depression in older adults.

METHODS

Data were used from the Netherlands Study of Depression in Older Persons (NESDO) of 359 persons aged 60 years or older, with a current diagnosis of major depressive disorder (MDD). Depressive subtypes (severe atypical, severe melancholic, and moderate severe subtype) that were previously identified through latent class analysis (LCA), were examined on differences in inflammatory markers including C-reactive protein (CRP), interleukin-6 (IL-6), and neutrophil gelatinase-associated lipocalin (NGAL), as well as cortisol parameters.

RESULTS

No differences in measures for inflammation and cortisol across subtypes were observed in uncorrected or for putative confounders corrected models.

LIMITATIONS

Several subjects had missing cortisol and inflammatory data, decreasing the power. However, results did not change after imputation analysis.

DISCUSSION

In this cohort of depressed older adults, no differences in inflammation and cortisol measures between depression subtypes were observed. This is probably due to the many (patho)physiological processes that are involved in aging, thereby clouding the results.

The course of apathy in late-life depression treated with electroconvulsive therapy; a prospective cohort study

OBJECTIVES

Apathy, a lack of motivation, is frequently seen in older individuals, with and without depression, with substantial impact on quality of life. This prospective cohort study of patients with severe late-life depression treated with electroconvulsive therapy (ECT) aims to study the course of apathy and the predictive value of vascular burden and in particular white matter hyperintensities on apathy course.

METHODS

Information on apathy (defined by a score of >13 on the Apathy Scale), depression severity, vascular burden, and other putative confounders was collected in at 2 psychiatric hospitals on patients with late-life depression (aged 55 to 87 years, N = 73). MRI data on white matter hyperintensities were available in 52 patients. Possible risk factors for apathy post-ECT were determined using regression analyses.

RESULTS

After treatment with ECT, 52.0% (26/50) of the depression remitters still suffered from clinically relevant apathy symptoms. In the entire cohort, more patients remained apathetic (58.9%) than depressed (31.5%). Presence of apathy post-ECT was not associated with higher age, use of benzodiazepines, or severity of apathy and depression at baseline. Less response in depressive symptomatology after ECT predicted post-treatment apathy. The presence of vascular disease, diabetes mellitus and smoking, and white matter hyperintensities in the brain was not associated with post-treatment apathy.

CONCLUSIONS

Apathy may perpetuate in individual patients, despite remission of depressive symptoms. In this cohort of patients with late-life depression, post-ECT apathy is not associated with white matter hyperintensities.

Big Five personality characteristics are associated with depression subtypes and symptom dimensions of depression in older adults

OBJECTIVE

This study examined the associations of personality characteristics with both subtypes and symptom dimensions of depression in older adults.

METHODS

Three hundred and seventy-eight depressed older adults participated in the Netherlands Study of Depression in Older Persons. Personality characteristics were assessed by the NEO-Five Factor Inventory. Subtypes and symptom dimensions of depression were determined using the Composite International Diagnostic Interview and the Inventory of Depressive Symptomatology (IDS). Multinomial logistic regression analyses were performed to examine the associations between personality and atypical, melancholic, and unspecified subtypes of major depression. Linear regression analyses examined the associations between personality and the IDS mood, somatic, and motivation symptom dimensions. The analyses were adjusted for confounders and additionally adjusted for depression severity.

RESULTS

Neuroticism, Extraversion, Conscientiousness, and Agreeableness were associated with specified (atypical or melancholic) major depression compared with unspecified major depression in the bivariate analyses but lost their significance after adjustments for functional limitations and severity of depression. Neuroticism was positively associated with the IDS mood and motivation symptom dimensions, also in the adjusted models. Further, Extraversion and Agreeableness were negatively associated with the IDS mood symptom dimension, and Extraversion and Conscientiousness were negatively associated with the IDS motivation symptom dimension. None was associated with the IDS somatic symptom dimension.

CONCLUSIONS

This study demonstrated the association of personality characteristics with mood and motivational symptoms of late-life depression. The lacking ability of personality to differentiate between melancholic and atypical depression seems to be largely explained by severity of depressive symptoms. Copyright © 2017 John Wiley & Sons, Ltd.

Depressive subtypes in an elderly cohort identified using latent class analysis

BACKGROUND

Clinical findings indicate heterogeneity of depressive disorders, stressing the importance of subtyping depression for research and clinical care. Subtypes of the common late life depression are however seldom studied. Data-driven methods may help provide a more empirically-based classification of late-life depression.

METHODS

Data were used from the Netherlands Study of Depression in Older People (NESDO) derived from 359 persons, aged 60 years or older, with a current diagnosis of major depressive disorder. Latent class analysis (LCA) was used to identify subtypes of depression, using ten CIDI-based depression items. Classes were then characterized using various sociodemographic and clinical characteristics.

RESULTS

The most prevalent class, as identified by LCA, was a moderate-severe class (prevalence 46.5%), followed by a severe melancholic class (prevalence 38.4%), and a severe atypical class (prevalence 15.0%). The strongest distinguishing features between the three classes were appetite and weight and, to a lesser extent, psychomotor symptoms and loss of interest. Compared with the melancholic class, the severe atypical class had the highest prevalence of females, the lowest mean age, the highest BMI, and highest prevalence of both cardiovascular disease, and metabolic syndrome.

LIMITATIONS

The strongest distinguishing symptoms, appetite and weight, could be correlated. Further, only longitudinal studies could demonstrate whether the identified classes are stable on the long term.

DISCUSSION

In older persons with depressive disorders, three distinct subtypes were identified, similar to subtypes found in younger adults. The strongest distinguishing features were appetite and weight; moreover, classes differed strongly on prevalence of metabolic syndrome and cardiovascular disease. These findings suggest differences in the involvement of metabolic pathways across classes, which should be considered when investigating the pathogenesis and (eventually) treatment of depression in older persons.

Loneliness in older adults is associated with diminished cortisol output

OBJECTIVE

Loneliness in older adults has been associated with increased mortality and health problems. One of the assumed underlying mechanisms is dysregulation of the hypothalamic-pituitary-adrenocortical axis (HPA-axis). The purpose of this study was to investigate whether loneliness in older adults is associated with HPA-axis dysregulation and whether this association differs between depressed and non-depressed persons.

METHODS

Cross-sectional data of 426 lonely and non-lonely older adults in the Netherlands Study of Depression in Older Persons (NESDO) were used. Linear regression analyses and multinominal logistic regression analyses were performed to examine the association between loneliness and morning cortisol, cortisol awakening response, diurnal slope and dexamethasone suppression ratio. In all analyses, confounders were introduced. In order to examine whether the association between loneliness and cortisol measures is different in depressed versus non-depressed persons, an interaction term for loneliness x depression diagnosis was tested.

RESULTS

Cortisol output in the first hour after awakening and dexamethasone suppression ratio was lower in lonely participants. There were no significant interactions between loneliness and depression diagnosis in the association with the cortisol measures.

CONCLUSION

This study is the first to investigate the association between the HPA-axis and loneliness in a large group of older adults aged 60-93years. We found lower cortisol output in the first hour after awakening and lower dexamethasone suppression ratio in lonely older depressed and non-depressed adults. Whether diminished cortisol output is the underlying mechanism that leads to health problems in lonely older adults is an interesting object for further study.

[ResPECT - a decade of Flemish-Dutch ECT research]

BACKGROUND

There is increasing clinical and scientific interest in electroconvulsive therapy (ECT).

AIM

To provide an overview of the main research findings of the Flemish-Dutch research consortium ResPECT.

METHOD

We report on our review of the relevant literature.

RESULTS

Our studies confirm that ECT is one of the most efficient treatments for depression in later life and for depression with psychotic features. Older people with age-related brain pathology can respond well to ECT. It is still preferable to apply a standard pulse-width because this increases the efficacy of the treatment and minimises the cognitive impact. Even vulnerable older people can react favourably to ECT.

CONCLUSION

Recent findings of the ResPECT consortium are providing new insights that are applicable in daily clinical practice. Research into mechanisms of action can also increase our understanding of the pathophysiology of severe depression.

The long-term outcome of subthreshold depression in later life

BACKGROUND

Subthreshold depression (SUBD) in later life is common and important as prodromal state and prominent risk factor in the development of major depressive disorder (MDD). Indicated prevention can reduce the incidence of MDD among people with SUBD substantially, but needs to be targeted to those that are truly at risk of developing MDD.

METHOD

N = 341 eligible participants with SUBD were included from the first (1992/1993), second (1995/1996) and third (1998/1999) cycle from the Longitudinal Aging Study Amsterdam (LASA) by using a two-stage screening design. LASA is an ongoing prospective cohort study in The Netherlands among the older population (55-85 years). At baseline (1992/1993) N = 3107 participants were interviewed and follow-up cycles were conducted every 3 years until 2008/2009, resulting in maximal 17 years of observational period. The proportion of people that developed MDD, remained SUBD, or recovered from SUBD was measured and Cox proportional regression analyses were performed to investigate 29 putative predictors of MDD and recovery from SUBD.

RESULTS

N = 153 (44.9%) recovered from SUBD, N = 138 (40.5%) remained chronically SUBD, and N = 50 (14.7%) developed MDD (incidence rate 15.1/1000 person-years). Women, high neuroticism, more chronic diseases, high body mass index, smoking and less social support predicted conversion to MDD. Men, low neuroticism and absence of pain predicted recovery from SUBD.

CONCLUSIONS

Although older people with SUBD are clearly at risk of developing MDD, the majority did not, even after a long and thorough follow-up. Given the risk factors that were uncovered, targeting and prevention of MDD in those at very high risk is feasible.

Psychiatric diagnoses underlying the phenocopy syndrome of behavioural variant frontotemporal dementia

INTRODUCTION

The frontotemporal dementia (FTD) consortium criteria (2011) emphasise the importance of distinguishing possible and probable behavioural variant FTD (bvFTD). A significant number of possible patients with bvFTD do not show functional decline and remain with normal neuroimaging over time, thus exhibiting the bvFTD phenocopy syndrome. A neurodegenerative nature is unlikely but an alternative explanation is missing. Our aim was to detect psychiatric conditions underlying the bvFTD phenocopy syndrome after extensive evaluation.

METHODS

We included patients with the bvFTD phenocopy syndrome whereby patients with probable bvFTD served as a control group. Patients had to have undergone both neurological and psychiatric evaluation. Their charts were reviewed retrospectively. Using both qualitative and quantitative methods, psychiatric and psychological conditions associated with the clinical syndrome were determined in both groups and their relative frequencies were compared.

RESULTS

Of 181 suspected bvFTD cases, 33 patients with bvFTD phenocopy syndrome and 19 with probable bvFTD were included. Recent life events, relationship problems and cluster C personality traits were the most prevalent psychiatric/psychological conditions. The frequency of these conditions was higher in the group of patients with the bvFTD phenocopy syndrome (n=28) compared to the probable bvFTD group (n=9) (χ(2) p<0.05).

CONCLUSIONS

This is the first study thoroughly exploring psychiatric causes of the bvFTD phenocopy syndrome, revealing that in most cases multiple factors played a contributory role. Our study gives arguments for neurological and psychiatric collaboration when diagnosing bvFTD. Prompt diagnosis of treatable psychiatric conditions is to be gained.

Tailored mental health care after nursing home admission: improving transfers of people with dementia with behavioral problems. An explorative study

OBJECTIVES

In the Netherlands, many community-dwelling people with dementia and behavioral disturbances and their family caregivers receive mental health care from a community psychiatric nurse (CPN). To promote continuity of care for these persons after moving to a nursing home, a transfer intervention was developed. The aim of this explorative study was to evaluate this intervention and its implementation.

METHOD

A qualitative explorative study design was used. CPNs visited professional nursing home carers, people with dementia and family caregivers six weeks after moving, advised on how to manage behavioral problems of their former clients and provided support to family caregivers. Twenty-two interviews were conducted with participants exposed to the intervention (5 CPNs, 5 family and 12 nursing home carers) and with 11 stakeholders (i.e., nursing home and mental health care managers, professional caregivers) to identify facilitators and barriers to the implementation. Data were collected in 2012 and 2013.

RESULTS

The follow-up visit at six weeks met the need for background information of new admitted patients and helped family caregivers close off the period prior to the move. It did not meet the original purpose of providing nursing home staff with advice about problem behaviors on time: six weeks after the move was experienced as too late.

CONCLUSION

The transfer intervention increased the awareness of nursing home staff about personal and behavioral characteristics of residents with dementia and supported caregivers in coping with the new situation. The timing of the intervention could be improved by scheduling it immediately after the move.

Childhood abuse, family history and stressors in older patients with bipolar disorder in relation to age at onset

OBJECTIVES

The aim of this study is to explore the family history of psychiatric disorders, childhood abuse, and stressors in older patients with Bipolar Disorder (BD) and the association of these variables with the age at onset of BD.

METHODS

The Questionnaire for Bipolar Disorder (QBP) and the Mini International Neuropsychiatric Interview (MINI-Plus) were obtained from 78 patients aged 60 and over to determine diagnosis, age at onset of the first affective episode, childhood abuse, family history of psychiatric disorders and past and recent stressful life events.

RESULTS

Increased family history of psychiatric disorders was the only factor associated with an earlier age at onset of BD. Less family history of psychiatric disorders and more negative stressors were significantly associated with a later age at onset of the first (hypo)manic episode.

LIMITATIONS

Age at onset, history of childhood abuse, and past stressful life events were assessed retrospectively. Family members of BD patients were not interviewed.

CONCLUSIONS

Our findings suggest that age at onset can define distinct BD phenotypes. More specifically there was a stronger heredity of BD and other psychiatric disorders in patients with an early age of onset of BD. Negative stressors may play a specific role in patients with a late age at onset of a first (hypo)manic episode.

Hypothalamic-pituitary-adrenal axis activity in older persons with and without a depressive disorder

BACKGROUND

Altered functioning of the hypothalamic-pituitary-adrenal axis (HPA-axis) has been associated with depression, but findings have been inconsistent. Among older depressed persons, both hyperactivity and hypo-activity of the HPA-axis were demonstrated. However, most studies were population-based studies, with single cortisol measurements, lacking insight into diurnal patterns of HPA-axis functioning. We aim to provide insight into functioning of the HPA-axis, assessed by various salivary cortisol samples, in depressed older adults and non-depressed controls.

METHODS

Data were derived from the Netherlands Study of Depression in Older Persons. Cortisol levels of older persons without a lifetime diagnosis of depression and/or anxiety (n=109) were compared with older persons with a 6-month major depression diagnosis (n=311). ANCOVA analyses and random coefficient analysis on the four morning cortisol samples were performed. A possible U-shaped association between cortisol and depression status was examined.

RESULTS

Depressed older persons showed higher morning cortisol levels at awakening (T1) and a less dynamic awakening response compared to non-depressed older persons. Dexamethasone suppression did not differ across groups. No U-shaped association between HPA-axis activity and depression was observed.

CONCLUSION

We demonstrated a hypercortisolemic state and a diminished ability to respond to the stress of awakening among depressed older persons. Previously it was shown, that hypercortisolemic states may indicate a lifelong biological vulnerability for depression. Our findings expand on previous literature by demonstrating that in older persons the HPA-axis may become less responsive to stress, culminating in a further dysregulation of the diurnal cortisol-rhythm, superimposed on - possibly lifelong - hypercortisolemic states.

[Hashimoto encephalitis and depression]

Hashimoto encephalitis (he) is an auto-immune disease, with 40-50% of patients developing psychopathology. This could require targeted treatment. HE and prednison could both cloud the identification of a concurrent depressive disorder. We saw a 78-year-old woman with he and a severe depression, and treated her succesfully with ect.

Theory of Mind differences in older patients with early-onset and late-onset paranoid schizophrenia

OBJECTIVE

Theory of Mind (ToM) is considered an essential element of social cognition. In younger schizophrenia patients, ToM impairments have extensively been demonstrated. It is not clear whether similar impairments can be found in older schizophrenia patients and if these impairments differ between older patients with early-onset and late-onset schizophrenia.

METHODS

Theory of Mind abilities were assessed using the Hinting Task in 15 older patients (age 60 years and older) with early-onset paranoid schizophrenia, 15 older patients with late-onset paranoid schizophrenia and 30 healthy controls. ANCOVA was performed to test differences between groups. Analyses were adjusted for level of education. Effect sizes, partial eta squared (ε(2) ), were computed as an indication of the clinical relevance of the findings.

RESULTS

Patients with early-onset schizophrenia scored significantly lower on the Hinting Task (mean 16.1; SD 4.3) compared with patients with late-onset schizophrenia (mean 18.6; SD 1.5) and with healthy controls (mean 19.0; SD 1.4). The effect size of this difference was large (ε(2)  = 0.2).

CONCLUSIONS

These results suggest that ToM functioning may be a protective factor modulating the age at onset of psychosis. Further studies into the relationship between social cognition and onset age of psychosis are warranted.

Big Five personality and depression diagnosis, severity and age of onset in older adults

BACKGROUND

Personality may play an important role in late-life depression. The aim of this study is to examine the association between the Big Five personality domains and the diagnosis, severity and age of onset of late-life depression.

METHODS

The NEO-Five Factor Inventory (NEO-FFI) was cross-sectionally used in 352 depressed and 125 non-depressed older adults participating in the Netherlands Study of Depression in Older Persons (NESDO). Depression diagnosis was determined by the Composite International Diagnostic Interview (CIDI). Severity of depression was assessed by the Inventory of Depressive Symptomatology (IDS). Logistic and linear regression analyses were applied. Adjustments were made for sociodemographic, cognitive, health and psychosocial variables.

RESULTS

Both the presence of a depression diagnosis and severity of depression were significantly associated with higher Neuroticism (OR=1.35, 95% CI=1.28-1.43 and B=1.06, p<.001, respectively) and lower Extraversion (OR=.79, 95% CI=.75-.83; B=-.85, p<.001) and Conscientiousness (OR=.86, 95% CI=.81.-.90; B=-.86, p<.001). Earlier onset of depression was significantly associated with higher Openness (B=-.49, p=.026).

LIMITATIONS

Due to the cross-sectional design, no causal inferences can be drawn. Further, current depression may have influenced personality measures.

CONCLUSIONS

This study confirms an association between personality and late-life depression. Remarkable is the association found between high Openness and earlier age of depression onset.

Increased risk of mortality associated with social isolation in older men: only when feeling lonely? Results from the Amsterdam Study of the Elderly (AMSTEL)

BACKGROUND

Loneliness has a significant influence on both physical and mental health. Few studies have investigated the possible associations of loneliness with mortality risk, impact on men and women and whether this impact concerns the situation of being alone (social isolation), experiencing loneliness (feeling lonely) or both. The current study investigated whether social isolation and feelings of loneliness in older men and women were associated with increased mortality risk, controlling for depression and other potentially confounding factors.

METHOD

In our prospective cohort study of 4004 older persons aged 65-84 years with a 10-year follow-up of mortality data a Cox proportional hazard regression analysis was used to test whether social isolation factors and feelings of loneliness predicted an increased risk of mortality, controlling for psychiatric disorders and medical conditions, cognitive functioning, functional status and sociodemographic factors.

RESULTS

At 10 years follow-up, significantly more men than women with feelings of loneliness at baseline had died. After adjustment for explanatory variables including social isolation, the mortality hazard ratio for feelings of loneliness was 1.30 [95% confidence interval (CI) 1.04-1.63] in men and 1.04 (95% CI 0.90-1.24) in women. No higher risk of mortality was found for social isolation.

CONCLUSIONS

Feelings of loneliness rather than social isolation factors were found to be a major risk factor for increasing mortality in older men. Developing a better understanding of the nature of this association may help us to improve quality of life and longevity, especially in older men.

[Key points for the treatment of the elderly with bipolar disorder]

BACKGROUND

There is a lack of research into the treatment of the elderly with bipolar disorder. The Dutch guidelines for the treatment of older persons with bipolar disorder are based primarily on research relating to younger adults.

AIM

To define key points for the treatment of bipolar disorder in later life.

METHOD

The working group on the elderly of the Dutch Foundation for Bipolar Disorder defined key points in several consensus meetings based on clinical experience and research literature.

RESULTS

Recommendations were drawn up for the treatment of the elderly with bipolar disorder relating to somatic comorbidity, pharmacotherapy, cognitive dysfunctions and psychosocial support.

CONCLUSIONS

In general the Dutch Guidelines for the treatment of Bipolar Disorder are applicable for the elderly, provided the key points are taken into consideration.

[The immune system and Alzheimer's disease]

BACKGROUND

It has still not been established unequivocally whether vascular risk factors and inflammatory reactions, determined by heredity, are a cause or a result of Alzheimer's disease

AIM

If the offspring of parents with AD have more risk factors and more frequent and severe inflammatory reactions than the offspring of parents without AD , this argues strongly in favor of a causal relationship between vascular risk factors, a pro-inflammatory cytokine response and AD.

AIM

To determine whether the offspring of parents with ad have more risk factors and more frequent and severe inflammatory reactions than the offspring of parents without ad. method Vascular risk-factors, pro-inflammatory cytokines and the apoe genotype were determined in 206 offspring of parents with ad and in 200 offspring of parents without AD.

RESULTS

Offspring of parents with ad carried more apoe epsilon4 than offspring of parents without ad (47% vs 21%). Middle-aged offspring of parents with a history of ad also had higher blood pressure and a greater atherosclerotic burden than the offspring of parents without AD. Also their response to the pro-inflammatory cytokine was significantly higher.

CONCLUSION

Hypertension and an inherited pro-inflammatory cytokine profile in middle age are early risk factors that contribute to the development of ad in old age. Offspring with a parental history of AD should therefore be offered screening and treatment for hypertension and have their blood pressure checked so that the development of AD in old age can be prevented.

[The inter-rater reliability of the Dutch version of the core. A validation study conducted among depressed elderly in-patients]

BACKGROUND

Assessment of psychomotor symptoms may lead to better classification of depressive disorders.

AIM

To test the inter-rater reliability of the Dutch version of CORE, an observational instrument for psychomotor symptoms.

METHOD

The CORE was used with 37 depressed in-patients and was scored by 5 psychiatrists. Intra-class correlation (ICCagreement) was tested.

RESULTS

ICCagreement of the total score (0.80), and the subscales non-interaction (0.74), retardation (0.70) and agitation (0.79) were sufficient.

CONCLUSION

The Dutch version of the CORE is a reliable instrument.

[Mania in late life: bipolar disorder as diagnosis by exclusion]

BACKGROUND

The underlying cause of mania in later life can be an early- or late-onset bipolar disorder or it can be a mood disorder arising from a physical illness, also known as 'a secondary mania'. Thorough diagnostic tests are needed to differentiate between the two types of mania.

AIM

To discuss the epidemiology, presentation, diagnostic considerations and treatment options when a mania develops in later life.

METHOD

The literature was studied systematically with the help of PubMed, the Cochrane Library, specialist manuals, Dutch guidelines and references.

RESULTS

So far, research into the incidence and prevalence of a mania in later life has been very limited. In making a differential diagnosis of this kind of mania the clinician has to consider not only the possibility of a bipolar disorder, severe depression or psychosis but also the possibility of delirium, dementia or secondary mania. According to some researchers, a mania can be caused by various neurological, systemic and pharmacological factors. Patients should be given somatic screening, including brain imaging. Lithium and antipsychotics are the agents of choice for treating a mania occurring as part of a bipolar disorder as well as for treating a secondary mania.

CONCLUSION

Epidemiologic research into late-onset mania is limited. In older patients it is important to identify -or rule out- somatic causes (secondary mania, dementia, delirium). Symptomatic treatment is more or less on the same lines as the treatment for mania in young adults. In cases of secondary mania maintenance treatment is not always necessary, but must be considered if risk factors for bipolar disorder are present.

[Elderly patients with schizophrenia: prevalence and distribution of age at onset in a psychiatric catchment area in Amsterdam]

BACKGROUND

Elderly patients with schizophrenia are underrepresented in the literature on schizophrenia, although they constitute a rapidly growing group with specific characteristics. The Amsterdam-based study entitled 'Schizophrenia in Old Age' is currently examining the clinical and psychosocial functioning of a cohort of older patients with schizophrenia.

AIM

To ascertain the one-year prevalence of schizophrenia and the distribution according to age at onset and gender in patients aged 60 years or over within a specific psychiatric catchment area.

METHOD

The study is based on the case register of a Mental Health Organisation during 1-7-2007 to 30-6-2008.

RESULTS

The one-year prevalence of schizophrenia was 0.55 % (95% ci: 0.46-0.64). In more than one in three patients the age of onset was 40 years or over. Women outnumbered men, even in the early-onset schizophrenia subgroup.

CONCLUSION

We found the prevalence of schizophrenia among older persons to be comparable to the prevalence among younger populations. The considerable number of patients who developed schizophrenia at an advanced age and the preponderance of women are distinguishing features of older persons with schizophrenia.

[Melancholia, psychomotor disturbance or depressed mood?]

Melancholia is a historical concept according to which the clinical condition is characterised by gloom, apprehension and psychomotor disturbance, vital symptoms and psychotic phenomena. The condition needs to be accurately diagnosed if treatment is to be appropriate. If a patient shows no clear signs of depression, psychomotor disturbance is often not recognised as a feature of severe depression and as a result treatment is delayed. On the basis of two case studies we show that psychomotor symptoms can be extremely important for an accurate clinical evaluation.

Vascular disease and apathy in old age. The Leiden 85-Plus Study

BACKGROUND

Apathy is defined as an important loss of motivation in all domains of daily functioning. Especially in old age, apathy might be a specific neuropsychiatric syndrome separate from depression. There are indications that apathy in elderly subjects is related to vascular disease.

OBJECTIVE

To assess the relation between vascular disease and apathy in subjects aged 85 years and older.

METHODS

The Leiden 85-plus Study is a prospective, population-based study of 500 elderly subjects. Vascular disease including myocardial infarction, angina pectoris or myocardial ischemia, claudicatio intermittens, and arterial surgery was determined at baseline. Symptoms of apathy were assessed annually from age 85 through 90 years using the apathy questions of the 15-item Geriatric Depression Rating Scale (GDS). Diagnostic accuracy of the apathy questions was validated using the Apathy Scale at age 90 years. The association between vascular disease and apathy was estimated both at baseline and longitudinally.

RESULTS

The apathy items of the GDS showed a sensitivity of 69% and a specificity of 85%. At baseline, 69 subjects with apathy but free of depression had significantly more cardiovascular pathologies compared to 287 subjects without apathy. In the 287 subjects who were free of apathy and depression, increase of apathy but not depression during follow-up was significantly higher for each additional cardiovascular pathology at baseline.

CONCLUSION

In community dwelling elderly, those with vascular disease were at higher risk of developing apathy but not depression. This suggests that apathy and depression in old age have different etiologies.

[Old age psychiatry in the Netherlands]

In recent years there have been significant developments in psychiatry for the elderly in the Netherlands. Epidemiological research has widened its scope, collaborating with other disciplines and thereby creating a range of new perspectives. Patient care is shifting gradually to the general hospital and psychiatry for the elderly has a definite place in the curriculum for trainee psychiatrists. Increasingly, integrated care arrangements are becoming available for elderly psychiatric patients with handicaps. Psychiatry for the elderly has obtained a firm foothold in the Netherlands and should be able to participate in and benefit from the developments that are expected in the years to come.

Cognitive functioning in elderly patients with early onset bipolar disorder

BACKGROUND

Very little is known about the long term cognitive sequelae of bipolar disorder.

AIM

To investigate neuropsychological functioning in older euthymic persons with early onset bipolar disorder.

METHOD

Fifteen older patients (age >60) with an early onset (<50 years) bipolar-I disorder in a euthymic mood were tested using a comprehensive neuropsychological test battery. Neuropsychological functioning was compared with that of a sex, age and education-matched group of 15 comparison subjects without mood disorders or memory complaints.

RESULTS

Bipolar subjects scored lower than comparison subjects on selective attention, verbal memory, verbal fluency and mental effort tests.

CONCLUSIONS

The findings suggest that euthymic bipolar patients are impaired across a range of cognitive domains. This could represent a trait-like cognitive disability related to the disease, as the impairments are comparable with those found in younger bipolar patients.

[The relationship between atherosclerosis, cognitive impairment, and depression in old age]

It has been suggested in the literature that atherosclerosis is a common causal pathway of cognitive impairment and late-onset depression, which may explain their co-occurrence in old age. In both the 'Leiden 85-plus Study' and the literature, strong evidence is found for a causal relationship between atherosclerosis and cognitive impairment, but there is less evidence for a causal relationship between atherosclerosis and late-onset depression. In the 'Leiden 85-plus Study', cognitive impairment was a risk factor for the development of late-onset depression, but depression in old age did not predict cognitive decline. This means that the prevention of atherosclerosis might prevent cognitive impairment and hence late-onset depression in old age.

Generalized atherosclerosis, cognitive decline, and depressive symptoms in old age

BACKGROUND

Atherosclerosis may be linked to cognitive decline and depression in old age.

METHODS

The Leiden 85-Plus Study is a prospective population-based study of 599 subjects from age 85 onward. The generalized atherosclerotic burden was rated by the number of cardiovascular pathologies at baseline, as assessed by history taking from treating physicians and EKG. Cardiovascular pathologies included myocardial infarction, angina pectoris or myocardial ischemia, claudicatio intermittens, and arterial surgery. Global cognitive function (Mini-Mental State Examination), attention (Stroop Test), processing speed (Letter Digit Coding Test), immediate recall memory (Word Learning Test-Immediate Recall), delayed recall memory (Word Learning Test-Delayed Recall), and depressive symptoms (15-item Geriatric Depression Scale) were assessed each year from ages 85 through 90. The prospective associations between both the generalized atherosclerosis rating and stroke with cognitive function and depressive symptoms were analyzed by linear mixed models adjusted for sex and level of education.

RESULTS

During follow-up, there was a significant cognitive decline and a significant increase of depressive symptoms. At baseline, a history of stroke was correlated with lower global cognitive function, slower processing speed, impaired immediate and delayed recall memory, and more depressive symptoms. In addition, a higher generalized atherosclerosis rating was correlated with impaired global cognitive function, lower attention, and a slower processing speed at baseline. During follow-up, a higher generalized atherosclerosis rating was associated with an accelerated decline of immediate recall memory and delayed recall memory. In contrast, there was no relation between the generalized atherosclerosis rating and depressive symptoms, either in the cross-sectional analysis or in the prospective analysis.

CONCLUSION

In the population at large, generalized atherosclerosis contributes to cognitive decline in old age but not to depression.

Prevalence and risk-factors for depression in elderly Turkish and Moroccan migrants in the Netherlands

BACKGROUND

Western societies host increasing number of elderly labour migrants from Turkey and Morocco. The article studied the prevalence of clinically significant depressive symptoms among elderly Turkish and Moroccan migrants compared with native Dutch elderly and if differences in prevalence rates were explained by known risk factors for depression and/or ethnic, migration-related factors.

METHODS

330 Turkish, 299 Moroccan, and 304 Dutch elderly (55-74 years) were interviewed (cross-sectionally) using the Center for Epidemiologic Depression Scale (CES-D). Potential risk factors included sex, income level, marital status, ethnic origin, chronic physical illnesses, limitations in daily functioning, migration and acculturation questions.

RESULTS

The prevalence of self-reported depressive symptoms (CES-D>or=16) was very high in elderly migrants, 33.6% for Moroccan and 61.5% for Turkish elderly. The prevalence of depressive symptoms in the native Dutch sample was similar to earlier studies in the Netherlands and abroad: 14.5%. Among migrants education and income level was very low and they had a high number of physical limitations and chronic medical illnesses. This only explained part of the ethnic differences found. In all three samples, depressive symptoms were associated with sex, chronic physical illness and physical limitations. In multivariate analysis, ethnic origin was uniquely associated with the presence of clinically significant depressive symptoms. Only a small number of remigration and acculturation items were associated with depressive symptoms in bivariate analysis.

CONCLUSIONS

The prevalence of clinically significant depressive symptoms among elderly migrants from Turkey and Morocco in the Netherlands is very high. Ethnicity was a strong independent risk factor.

Discrepancy between opinion and attitude on the practice of ECT by psychiatrists specializing in old age in the Netherlands

BACKGROUND

Current guidelines consider electroconvulsive therapy (ECT) in the Netherlands a treatment of choice for a depressive disorder with psychotic features, severe suicidal behavior, severe physical exhaustion, or resistance to treatment with antidepressants (consecutively SSRIs, TCAs, lithium, MAO inhibitors). It is advised to use ECT early on in the treatment of depressed elderly patients. In practice, ECT is applied to only a minority of depressed elderly patients in the Netherlands. This situation dates back to the 1970s, in which strong aversive opinions toward ECT grew in the Netherlands, largely as a reaction to the malpractice of ECT in that time and influenced by social-cultural opinions toward psychiatry. Negative attitudes among professionals and lack of knowledge may contribute to the under use in depressed elderly patients.

METHODS

A postal questionnaire was sent to 152 psychiatrists who specialize in old age to assess their opinions and attitudes toward ECT.

RESULTS

Only a small minority thought ECT was a treatment of choice in a depressive disorder with psychotic features (4%), severe suicidal risk (2%), or physical exhaustion (5%). The majority of the psychiatrists had strongly reserved opinions in considering ECT as a treatment of first, second or third choice in depressed elderly patients, even in treatment-resistant depressive disorders.

CONCLUSIONS

Many psychiatrists who specialize in old age in the Netherlands divert from the current guidelines and are reluctant toward using ECT as a treatment of choice in a number of specific, clinical situations. This might be a major contributing factor to the present and past underuse of ECT in depressed elderly patients in the Netherlands.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

The efficacy and safety of ECT in depressed older adults: a literature review

BACKGROUND

Although little doubt exists among practising clinicians in old age psychiatry about the efficacy and safety of ECT in depression, opinions about acceptability differ widely. The objectives of this review were to determine the efficacy and safety of ECT based on both randomised and non-randomised evidence in elderly with a major depressive disorder.

METHODS

Randomised and non-randomised studies on efficacy and safety of ECT in elderly with and without concomitant disorders such as cerebrovascular disorders, Alzheimer's dementia, vascular dementia and Parkinson's disease were selected. Literature was systematically searched in a number of electronic databases.

RESULTS

Although 121 studies were included in the review process, only four provided randomised evidence. No negative studies with respect to efficacy were found. ECT is effective in the acute treatment of late life depression. ECT is generally safe, although a number of serious complications possibly related to ECT have been described. Most of the objectives of this review could not be answered or refuted with certainty, because firm randomised evidence on the efficacy and safety of ECT in the depressed elderly is missing.

CONCLUSIONS

ECT is effective in the acute treatment of late life depression and is generally safe. Important questions such as the relative efficacy of ECT over antidepressants, the long-term efficacy of ECT, morbidity and mortality related to ECT, cost-effectiveness and the efficacy of ECT in subgroups of patients cannot be answered and need to be studied further.

[Apathy syndrome: a clinical entity?]

Apathy is defined as a disorder of motivation that expresses itself at an emotional, cognitive and behavioural level. Apathy can occur as a symptom and a syndrome. In the recent years diagnostic criteria and a number of scales for measuring apathy in elderly with psychiatric or neurological disorders have been introduced. Two scales are specifically developed to measure apathy, the Apathy Evaluation Scale (AES) from Marin and the Apathy Scale (AS) from Starkstein. Both scales have been translated into Dutch. The AS is more convenient. The AS in addition can be used when applying the criteria for the apathy syndrome which has been introduced in 2001 by Starkstein. In addition, the Neuropsychiatric Inventory (NPI) and the 'Gedragsobservatieschaal voor de Intramurale Psychogeniatrie' (GIP) (a scale in Dutch) have an apathy domain. Conceptual problems surrounding apathy have only partly been resolved. The criteria for the apathy syndrome can only be used for assessing the extent of the problem. Apathy and depression are strongly correlated. Studies show that apathy as a syndrome can occur without concomitant depression in the elderly, but regularly occurs besides a depressive disorder, in percentages varying between 9% and 53% of the population under study. Especially the varying validity of an apathy syndrome in relation to late life depression needs further clarification.

Electroconvulsive therapy for the depressed elderly

BACKGROUND

Depressive disorder is a common mental disorder in old age, with serious health consequences such as increased morbidity, disability, and mortality. The frailty of elderly may seriously hamper the efficacy and safety of pharmacotherapy in depressed elderly. Electroconvulsive therapy (ECT) in depressed elderly therefore may be an alternative to treatment with antidepressants.

OBJECTIVES

To assess the efficacy and safety of ECT (compared to simulated ECT or antidepressants) in depressed elderly.

SEARCH STRATEGY

We searched the CCDANCTR database, Medline 1966-2000, EMBase 1980-2000, Biological abstracts 1985-2000, Cinahl 1982-2000, Lilacs from 1982 onwards, Psyclit 1887-2000, Sigle 1980-2000. The reference lists of relevant papers were scanned for published reports. Hand searching of the Journal of ECT and the Journal of Geriatric Psychiatry was done. Based on the title of the publication and its abstract, non-eligible citations were excluded.

SELECTION CRITERIA

Data were independently extracted by at least two reviewers. Randomised, controlled trials on depressed elderly (> 60 years) with or without concomitant with conditions like cerebrovascular disease, dementia of the Alzheimer's type, vascular dementia or Parkinson's disease were included.

DATA COLLECTION AND ANALYSIS

Data were independently extracted by at least two reviewers. For continuous data weighted mean differences (WMD) between groups were calculated.

MAIN RESULTS

Randomised evidence is sparse. Only three trials could be included, one on the efficacy of real ECT versus simulated ECT (O'Leary et al 1994), one on the efficacy of unilateral versus bilateral ECT (Fraser 1980) and the other comparing the efficacy of ECT once a week with ECT three times weekly (Kellner 1992). All had major methodological shortcomings; data were mostly lacking essential information to perform a quantitative analysis. Although the O'Leary study concluded that real ECT was superior over simulated ECT, these conclusions need to be interpreted cautiously. Only results from the second trial (unilateral versus bilateral ECT) could be analysed, not convincingly showing efficacy of unilateral ECT over bilateral ECT, WMD 6.06 (CI -5.20,17.32). Randomised evidence on the efficacy and safety of ECT in depressed elderly with concomitant dementia, cerebrovascular disorders or Parkinson's disease is completely lacking. Possible side-effects could not be adequately examined because the lack of randomised evidence and the methodological shortcomings.

REVIEWER'S CONCLUSIONS

None of the objectives of this review could be adequately tested because of the lack of firm, randomised evidence. Given the specific problems in the treatment of depressed elderly, it is of importance to conduct a well designed randomised controlled trial in which the efficacy of ECT is compared to one or more antidepressants.

The prognosis of depression in old age: outcome six to eight years after clinical treatment

Previous studies suggest that the short-term outcome in severely depressed elderly in The Netherlands is worse compared to other studies in the Western world. The present study examines the long-term prognosis of hospitalized elderly patients with major depressive disorder and possible predictors of outcome. One hundred and five elderly inpatients with unipolar major depression, admitted by regional mental health services in a geographically delimited area, were evaluated six to eight years after index episode by trained residents using a structured diagnostic interview (C.I.D.I.) The GP was interviewed using a standard questionnaire. At follow-up 40% of the original sample had died. Of the survivors 33% had fared well, 24% had a relapsing course, 22% had residual symptoms, 11% were continuously ill, and 9% had probable dementia. With respect to prognostic factors, personality disorder predicted a worse outcome. All patients with a major depressive disorder at follow-up received specialised care and used antidepressants. None of the patients received ECT. The mortality rate in clinically treated elderly with major depressive disorder is high. Among survivors the long-term prognosis in The Netherlands is comparable with other studies to date. The presence of a personality disorder predicts worse outcome. Though the accessibility of services seems to be good, more vigorous treatment was not applied.

[Electroconvulsive therapy effective and safe in 55 patients aged 56 years and older with mood disorders and physical comorbidity]

OBJECTIVE

To determine the efficacy and safety of electroconvulsive therapy (ECT) in patients aged 56 years and older with mood disorders who had failed to respond to pharmacotherapy.

DESIGN

Retrospective, descriptive.

METHOD

Demographic data, illness and treatment characteristics were registered for all patients (age > or = 56 years) treated with ECT in the period 1 January 1998 to 31 December 2000. The efficacy of ECT was evaluated with the 'Montgomery-Asberg depression rating scale' (MADRS) and cognitive side effects were evaluated with the 'Mini-mental state examination' (MMSE). Descriptive statistical methods were used for the analysis.

RESULTS

A total of 58 treatments were evaluated in 55 patients with a mean age of 73 years. Most patients had a recurrent depressive disorder with physical comorbidity that did not respond to pharmacotherapy. An average of 12 ECT sessions were given per treatment. In patients where a MADRS score was known before and after ECT, 74% exhibited a significant improvement and 48% reached a complete remission of the depression. Cognitive side effects occurred in 28% of the patients. No serious physical complications were reported.

CONCLUSION

ECT is an essential means of intervention in treating mood disorders of the elderly and should be considered in an earlier phase, especially in patients with physical comorbidity.

The implication of selection bias in clinical studies of late life depression: an empirical approach

OBJECTIVES

It is supposed that selection bias precludes the extrapolation of results of studies carried out in a clinical setting to the general population. There is little empirical evidence demonstrating the degree to which those depressed in the community are different from those treated in clinical settings. This study compared elderly patients with major depression admitted to a psychiatric hospital with those living in the community.

METHODS

All elderly (55 years and older) patients admitted between 1990 and 1992 to a psychiatric hospital with DSM major depression as the primary diagnosis (n=104), were compared with all elderly patients with the same diagnosis (n=59) who were participating in a large community study (Longitudinal Aging Study, Amsterdam). Data were gathered from the clinical sample using chart-reviews while the community-based sample was interviewed. The two groups were compared with respect to differences in demographic variables, presenting symptoms, risk factors and treatment.

RESULTS

The following characteristics were significantly more prevalent in the clinical sample: late onset of the depression, threat of suicide, conflicts with significant others and use of antidepressant medication. Chronic physical illness was the only characteristic that was more prevalent in the community sample.

CONCLUSION

The results confirm that elderly patients treated in clinical psychiatry represent a group with more threatening and more disruptive depressive illness. Major depression in the community was more often associated with chronic physical illness, which may hamper the recognition and treatment of depression. As the two samples were similar in all other respects, selection bias, hampering comparison of results of studies carried out across treatment settings, appears to have a very limited effect.

[Electroconvulsive therapy in late life depression: a review]

Electroconvulsive therapy is an important treatment of depressive states in late life. However in the Netherlands ECT is not often practiced and mostly indicated after a long period of fruitless clinical therapy. The primary aims of this literature study were to review the efficacy of ECT in late life depression, to identify predictors of good response, to discuss contraindications, side effects and finally modifications of technique. Eighteen studies were found addressing the topic of efficacy. Outcome ranged between 50%-100% clinically significant improvement. Positive predictors are melancholic features and delusional depression. Unlike in younger patients hypochondriacal symptoms and anxiety do not predict a negative outcome in older patients. ECT has been used successfully in depression complicated by dementia, cognitive decline and cerebrovascular disease. Depression in Parkinson's disease may be a special indication where ECT may have a positive effect on motor symptoms. There are no firm indications of long term cognitive decline associated with ECT. Guidelines for practicing ECT (unipolar, brief pulse and anaesthesia) are in line with the state of the art in the literature. It is concluded that, especially in severe depression associated with comorbidity, current Dutch practice in using ECT, often leads to unwarranted delay.

[Tardive dyskinesia: an increased risk of neuroleptics in elderly women]

Tardive dyskinesia is a side-effect of antipsychotic drugs. Elderly women with depression are at risk even on a low dosis. A case is presented in which a typical depression was treated with high dosis haloperidol resulting in orofacial dyskinesia and a less frequently seen grunting. Correct diagnosis, indication, dosis monitoring and regular evaluation of possible side-effects are the most important factors to prevent these serious invalidating conditions.