Recommendations for the management of behavioral and psychological symptoms of dementia

BACKGROUND

The behavioral and psychological symptoms of dementia (BPSD) are common, serious problems that impair the quality of life for both patient and caregiver. In order to provide recommendations based upon the best available evidence, a qualitative literature review was performed.

METHODS

A search of the English language medical literature published between 1966 and 2000 was performed. The quality of the studies was assessed by considering the subjects, trial design, analysis and results. Final recommendations were based upon the quality of available evidence.

RESULTS

The management of BPSD begins with a thorough assessment to search for underlying causes of behaviour change. Concomitant medical illness should be treated and sensory impairment ameliorated. Nonpharmacological approaches should be instituted prior to medication use. These interventions include music, light, changes in level of stimulation and specific behavioral techniques. Antipsychotics are the best studied pharmacological intervention for agitation and aggression and have demonstrated modest but consistent efficacy. Antidepressants such as trazodone and selective serotonin re-uptake inhibitors, as well as anticonvulsants such as carbamazepine and valproic acid have also demonstrated efficacy. Benzodiazepines can be used for short-term treatment as p.r.n. agents when necessary. Pharmacotherapy must be monitored closely for both effectiveness and side effects, with consideration of medication withdrawal when appropriate.

CONCLUSION

The management of BPSD can significantly improve the quality of life for the patient and caregiver. Their assessment and management are essential components of the treatment of dementia.

Use of SSRIs in the elderly: obvious benefits but unappreciated risks

Selective serotonin reuptake inhibitors (SSRIs) are frequently recommended as a first-line treatment for depression in elderly patients. The evidence for this recommendation appears to be weak because studies that have examined the comparative efficacy, safety, tolerability and effectiveness of SSRIs and tricyclic antidepressants (TCAs) suggest that there are few advantages for one over another. Furthermore, a number of potential adverse effects of SSRIs are unappreciated risks. These include falls, hyponatremia, weight loss, sexual dysfunction and drug interactions. These potential risks, however, appear to be equally balanced by advantages such as fewer anticholinergic effects, a benign cardiovascular profile, ease of use and safety in overdose. SSRIs and TCAs have relative risks and benefits, and clinicians must maintain expertise in prescribing for elderly patients given both the frequency and severity of depressive disorders in late life.

Probing peripheral and central cholinergic system responses

OBJECTIVE

The pharmacological response to drugs that act on the cholinergic system of the iris has been used to predict deficits in central cholinergic functioning due to diseases such as Alzheimer's disease, yet correlations between central and peripheral responses have not been properly studied. This study assessed the effect of normal aging on (1) the tropicamide-induced increase in pupil diameter, and (2) the reversal of this effect with pilocarpine. Scopolamine was used as a positive control to detect age-dependent changes in central cholinergic functioning in the elderly.

DESIGN

Randomized double-blind controlled trial.

PARTICIPANTS

Ten healthy elderly (mean age 70) and 9 young (mean age 33) volunteers.

INTERVENTIONS

Pupil diameter was monitored using a computerized infrared pupillometer over 4 hours. The study involved 4 sessions. In 1 session, tropicamide (20 microL, 0.01%) was administered to one eye and placebo to the other. In another session, tropicamide (20 microL, 0.01%) was administered to both eyes, followed 23 minutes later by the application of pilocarpine (20 microL, 0.1%) to one eye and placebo to the other. All eye drops were given in a randomized order. In 2 separate sessions, a single dose of scopolamine (0.5 mg, intravenously) or placebo was administered, and the effects on word recall were measured using the Buschke Selective Reminding Test over 2 hours.

OUTCOME MEASURES

Pupil size at time points after administration of tropicamide and pilocarpine; scopolamine-induced impairment in word recall.

RESULTS

There was no significant difference between elderly and young volunteers in pupillary response to tropicamide at any time point (p > 0.05). The elderly group had a significantly greater pilocarpine-induced net decrease in pupil size 85, 125, 165 and 215 minutes after administration, compared with the young group (p < 0.05). Compared with the young group, the elderly group had greater scopolamine-induced impairment in word recall 60, 90 and 120 minutes after administration (p < 0.05).

CONCLUSION

There is an age-related pupillary response to pilocarpine that is not found with tropicamide. Thus, pilocarpine may be useful to assess variations in central cholinergic function in elderly patients.

Donepezil for behavioural disorders associated with Lewy bodies: a case series

Dementia with Lewy bodies (DLB) has been associated with important behavioural disturbances, such as psychotic symptoms. Unfortunately, neuroleptic sensitivity in these patients limits effective pharmacological management of these symptoms. Seven patients, five male and two female (mean age 75.3+/-4.7 years, range 68-81), diagnosed with DLB were treated with the acetylcholinesterase inhibitor donepezil (5-10 mg once daily) to determine its effect on treating behavioural disorders. Although the intended length of treatment was a minimum of 8 weeks, only three patients completed 8 weeks of therapy, one patient completed 6 weeks, two patients completed 4 weeks and one patient was discontinued after 5 days. The primary outcome (behavioural disturbances) was measured prospectively by the Neuropsychiatric Inventory (NPI), while other outcomes included cognition (Mini-Mental State Examination (MMSE)) and Clinical Global Impression. Three of the seven subjects showed marked improvement in behaviour, with NPI scores dropping significantly over time. Donepezil therapy was discontinued prematurely in three of the cases due to insufficient response and/or adverse events. Overall, five of the seven patients were rated at least minimally improved in behavioural symptoms. Our experience with donepezil in this group of patients shows promise. Given the limited experience with this agent in treating behavioural disorders associated with DLB, further studies are warranted.

Dose-response evaluation of the interaction between sertraline and alprazolam in vivo

In vitro data show the inhibition of alprazolam metabolism by sertraline via CYP3A4; therefore, using a randomized, double-blind, placebo-controlled design, the authors conducted this study to assess the potential for similar in vivo inhibition in humans. Ten healthy volunteers participated in two test sessions (placebo/alprazolam 1 mg orally) before the initiation of sertraline treatment. Blood samples were obtained over a 32-hour period and pharmacodynamic measures (sedation, psychomotor performance, memory function) were obtained over an 8-hour period. After a minimum of 2 weeks of daily sertraline self-administration (50, 100, or 150 mg/day), test sessions were repeated. Alprazolam concentrations (N = 6, 4, and 6 at sertraline doses of 50, 100, and 150 mg/day, respectively) showed no significant changes based on peak concentration (Cmax), time to maximum concentration (Tmax), elimination half-life (t1/2[beta]), and area under the concentration-time curve (AUC(0-8)), with the exception of a reduced Cmax in the 50 mg/day group. Similarly, dynamic data showed no significant variations based on peak effect, Tmax, and AUC(0-infinity), with the exception of increased peak impairment in one measure of psychomotor performance. No differences were detected between placebo alone and placebo plus sertraline. These findings suggest that sertraline (50-150 mg/day) does not alter the single-dose kinetics or dynamics of alprazolam; therefore, the combination may be prescribed without an increased risk of alprazolam toxicity.

Donepezil for behavioural disorders associated with Lewy bodies: a case series

Dementia with Lewy bodies (DLB) has been associated with important behavioural disturbances, such as psychotic symptoms. Unfortunately, neuroleptic sensitivity in these patients limits effective pharmacological management of these symptoms. Seven patients, five male and two female (mean age 75.3+/-4.7 years, range 68-81), diagnosed with DLB were treated with the acetylcholinesterase inhibitor donepezil (5-10 mg once daily) to determine its effect on treating behavioural disorders. Although the intended length of treatment was a minimum of 8 weeks, only three patients completed 8 weeks of therapy, one patient completed 6 weeks, two patients completed 4 weeks and one patient was discontinued after 5 days. The primary outcome (behavioural disturbances) was measured prospectively by the Neuropsychiatric Inventory (NPI), while other outcomes included cognition (Mini-Mental State Examination (MMSE)) and Clinical Global Impression. Three of the seven subjects showed marked improvement in behaviour, with NPI scores dropping significantly over time. Donepezil therapy was discontinued prematurely in three of the cases due to insufficient response and/or adverse events. Overall, five of the seven patients were rated at least minimally improved in behavioural symptoms. Our experience with donepezil in this group of patients shows promise. Given the limited experience with this agent in treating behavioural disorders associated with DLB, further studies are warranted.

Functional and neuroanatomic correlations in poststroke depression: the Sunnybrook Stroke Study

BACKGROUND AND PURPOSE

The purpose of our study was to determine the functional and neuroanatomic correlates of poststroke depressive symptoms.

METHODS

Patients with consecutive admissions to a regional stroke center for new-onset unilateral hemispheric stroke who met World Health Organization and National Institute of Neurological and Communicative Disorders and Stroke criteria were eligible for inclusion in a longitudinal study. Acutely, patients underwent CT scanning, and at 3 months and 1 year after stroke, depressive symptoms were assessed by using both the Montgomery-Asberg Depression Rating Scale and the Zung Self-Rating Depression Scale. The Functional Independence Measure (FIM) served as an indication of functional outcome and was obtained at 1 month, 3 months, and 1 year after stroke, along with other demographic information. The Talairach and Tournoux stereotactic atlas was used for the primary determination of CT lesion localization. Lesion proximity to the anterior frontal pole was also measured.

RESULTS

Eighty-one patients participated in the longitudinal study. Stepwise linear regression analyses generated a highly significant model (F(3,76)=9.8, R(2)=28%, P<0.0005), with lower 1-month total FIM scores, living at home, and damage to the inferior frontal region predicting higher depression scores at 3 months. Similarly, lower 3-month total FIM scores correlated with higher 3-month depression scores, and lower 1-year total FIM scores correlated with higher 1-year depression scores.

CONCLUSIONS

Functional measures correlated with poststroke depression across time and, together with neuroanatomic measures, predicted depressive symptoms longitudinally. Although inferior frontal lesion location, irrespective of side, appeared to play a role as a risk factor in this study, the degree of functional dependence after stroke imparted the greatest risk.

Effectiveness of gabapentin for the treatment of behavioral disorders in dementia

Twelve patients with moderate to severe dementia and severe behavioral disorders were treated with open-label gabapentin (200-1,200 mg/day) for 8 weeks in a prospective case-series design. Patients were nonresponders to previous trials of neuroleptics. Behaviors were measured at 2-week intervals with the Neuropsychiatric Inventory (NPI), the Cohen-Mansfield Agitation Inventory (CMAI), and the Clinical Global Impression Scale (CGI). Gabapentin was generally well tolerated in this population. Although 42% of patients experienced adverse events such as gait instability and sedation, only two patients discontinued treatment prematurely because of adverse events. Average patient scores for the CMAI and the NPI remained unchanged after gabapentin. On the CGI, two patients were much improved, three were minimally improved, six were unchanged, and one was minimally worse. Gabapentin may have a role in treating a subgroup of dementia patients with severe behavioral disorders who have not responded to neuroleptics.

Prevalence of antidepressant use among older people: population-based observations

OBJECTIVE

To assess the prevalence of antidepressant use with respect to age, gender, and time during a 5-year period from 1993 to 1997.

DESIGN

A retrospective, population-based study in which data regarding a cross-sectional series of annual antidepressant use were obtained from administrative claims and census databases for more than 1.4 million older persons during calendar years 1993 through 1997.

PARTICIPANTS

All residents of Ontario aged 65 or older.

MAIN OUTCOME MEASURES

Changes in the prevalence of antidepressant users as a function of age group, gender, and time.

RESULTS

A general, positive, linear trend in the prevalence of antidepressant users with increasing age group was consistently detected regardless of gender and year assessed (P < .001 for both genders and all years). The age-adjusted relative risk of women being dispensed an antidepressant relative to men was significantly higher during each year but seemed to decrease slightly over time: 1.74 (95% CI, 1.72-1.76) in 1993 and 1.65 (95% CI, 1.63-1.67) in 1997. The multiple linear regression model revealed significant relationships between the prevalence of antidepressant users and increasing age group, female gender, and increasing year of assessment (P < .001 for each variable). The prevalence was observed to range from a low of 5.6% in 65 to 69-year-old men in 1993 to a high of 17.2% among 85 to 89-year-old women in 1997.

CONCLUSIONS

Our findings reveal that the prevalence of antidepressant users is dynamic and is significantly and independently associated with age, gender, and time of assessment.

The effectiveness of antidepressants in elderly depressed outpatients: a prospective case series study

BACKGROUND

This study examined the effectiveness of antidepressants in a group of elderly depressed outpatients by assessing depression prevalence and recording adverse events over time.

METHOD

A prospective practice-based observational study (1991-1994) included consecutive outpatients at least 65 years of age with a DSM-III-R diagnosis of major affective disorder and who were prescribed antidepressant medications. Depressive symptoms were examined over time (stage 1 = 0 to 2 months; stage 2 = 2 to 6 months; stage 3 = 6 months to 2 years) with the Montgomery-Asberg Depression Rating Scale (MADRS). The cutoff scores of MADRS <18 and MADRS > or =18 were used in survival statistics. Adverse events were recorded systematically.

RESULTS

A total of 213 patients were seen over 2677 visits (mean +/- SD age = 75.5+/-6.1 years). MADRS scores for 85.8% of patients declined to below 18 within the first 2 months of antidepressant treatment. MADRS scores were above 18 for 37.3% of patients after 6 months and for 37.1% after 2 years. The mean time to decline in MADRS scores to below 18 in stage 1 was 36.1 days, and there was a significant difference between the antidepressant classes (log rank = 8.3, df = 3, p = .04), with tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs)/reversible inhibitors of monoamine oxidase A (RIMAs) having shorter times to response. The mean time to reach scores above cutoff during stage 2 was 144.3 days (log rank = 5.7, df = 3, p = .13) and during stage 3, 538.6 days (log rank = 9.8, df = 3, p = .02). Patients receiving TCAs and MAOIs/RIMAs had longer durations of MADRS scores below cutoff during stage 3 than those taking atypical antidepressants and selective serotonin reuptake inhibitors. All antidepressant classes reported similar adverse event profiles.

CONCLUSION

This study systematically examined antidepressant effectiveness in a prospective design. TCAs and MAOIs/RIMAs were shown to be superior in effectiveness during 2 of the 3 treatment stages.

The use of non-prescription sleep products in the elderly

While sleep disorders are common in the elderly, the use of non-prescription products for sleep in this population has not been fully evaluated. The objectives of this project were to assess the use, perceived effectiveness and toxicity of non-prescription sleep products in an ambulatory elderly population.

METHODS

A self-administered 20-question survey was distributed to seniors, aged 60 years or more, during hospital or pharmacy visits.

RESULTS

Of the total respondents (N=176, mean age 74+/-7 years, 59% female), 84 (48%) indicated that they had used one or more therapies for sleep within the past year. These included non-prescription products (50% of therapies), prescription products (17%) and non-drug activities such as walking or drinking milk (34%). For those individuals who had used a non-prescription product in the past year (N=47, 27% of total respondents), the most frequently used products were: dimenhydrinate (21%), acetaminophen (19%), diphenhydramine (15%), alcohol (13%) and herbal products (11%). Most took them at least 1 day per week (79%) and 32% took them daily. These products subjectively improved sleep latency (mean 32 vs 61 minutes, p<0.001), number of nocturnal awakenings (mean 2 vs 3 awakenings, p<0.001) and total hours of sleep (mean 6.6 vs 5.4 hours, p<0.001). Mild side-effects were reported by 35 respondents (75%), the most common being dry mouth (N=22) and daytime drowsiness (N=13). Respondents were taking an average of four (SD+/-3, range 0-10) other medications currently.

CONCLUSIONS

Non-prescription products are widely used by this population of ambulatory elderly for sleep disturbances. Most of the products were not marketed for sleep; however, they were perceived to be efficacious with low toxicity. The potential for drug interaction is high. Further research is warranted to evaluate the safety and effectiveness of non-prescription sleep products in the elderly.

The nature and management of mania in old age

Mania in old age represents a syndrome involving affective vulnerability in association with neurologic lesions that affect specific areas of the brain. Most patients suffering from mania in late life have converted to bipolarity later in life after many years and often repeated episodes of depression or else have developed mania in association with specific neurologic insults, particularly cerebrovascular disease (vascular mania). The outcome is generally worse in mania than in depression with higher prevalence of cognitive dysfunction, persistent symptoms, and greater mortality. The management of elderly bipolar patients with mood stabilizers reflects the experience with a mixed age population primarily involving the use of lithium carbonate and valproate in appropriately adjusted dosages and serum levels, with valproate having an edge on better tolerability. The use of neuroleptics is often unavoidable in initial stabilization, and electroconvulsive therapy can be life-saving in severely overactive or refractory patients.

Bipolar disorder in old age

OBJECTIVE

To review the classification, clinical characteristics, and epidemiology of bipolar disorders in old age with a special focus on neurologic comorbidity, high mortality, and management.

QUALITY OF EVIDENCE

Most available data is gleaned from retrospective chart reviews and cohort studies. Treatment recommendations are based on evidence from younger populations and a few anecdotal case reports and series involving elderly people.

MAIN MESSAGE

While relatively rare in the community setting, mania in old age frequently leads to hospitalization. It is associated with late-onset neurologic disorders (especially cerebrovascular disease) involving the right hemisphere and orbitofrontal cortex. Prognosis is relatively poor; morbidity and mortality rates are high. Management of bipolarity includes cautious use of mood stabilizers, especially lithium and divalproex.

CONCLUSIONS

Mania in old age should trigger a careful assessment of underlying neurologic disease, especially cerebrovascular disease. Close clinical follow up is essential.

Clock tests in depression, Alzheimer's disease, and elderly controls

OBJECTIVE

While clock-drawing tests are commonly used to screen for cognitive impairment in the elderly, little is known about the performance of elderly depressives.

METHODS

We compared thirty-three patients with major depression to forty-two Alzheimer's disease and thirty age-matched controls on clock-drawing, copying, and reading.

RESULTS

Patients with Alzheimer's disease had significantly lower scores on clock-drawing, copying, and reading than patients with depression or the controls (p < 0.05). Patients with depression did not differ significantly from controls on quantitative scores or qualitative errors.

CONCLUSIONS

Clock tests may be useful for identifying depressed patients with underlying dementia.

The use of clock tests in schizophrenia

Though clock drawing tests are well recognized as measures of cognitive function, there is little data on the performance of patients with schizophrenia. We compared 24 patients with schizophrenia to 24 healthy, age-matched controls on clock drawing, copying, and reading. Patients with schizophrenia performed significantly worse on clock drawing and copying despite the fact that the groups had similar scores on the MMSE. Worse performance was associated with higher scores on the BPRS. Clock drawing and copying may be useful for the assessment of cognition in schizophrenia, and the monitoring of cognitive changes associated with antipsychotic medication.

The importance of lesion location in poststroke depression: a critical review

BACKGROUND

Mood disorder may be a specific complication of stroke. An earlier finding of an association between left anterior lesions and poststroke depression stimulated interest in the significance of stroke lesion characteristics. Subsequent research efforts, however, often failed to replicate this finding.

OBJECTIVE

This paper represents a critical appraisal of hemispheric lesion localization studies by computed tomography (CT) scanning in poststroke depression.

METHOD

Systematic selection of original studies involved a Medline search and a review of the bibliographies of retrieved articles for additional references. Two sets of inclusion criteria were independently applied to the studies by 2 observers blind to authorship, affiliation, and journal name. Studies that satisfied minimum inclusion criteria, as determined by consensus, were included in the review.

RESULTS

Twenty-six original articles were retrieved by the search. Thirteen studies satisfied all or nearly all of the minimum criteria for inclusion. Six of those studies found no difference between right- and left-hemisphere lesions leading to depression. Two studies found right-sided lesions more likely to be associated with depression, while 4 studies found depression to be associated more often with left-sided lesions. One study matched subjects with and without depression for lesion location and size to identify nonlesion risk factors. All studies suffered from methodological limitations, and no studies were completely comparable with respect to sample, timing and analysis of CT scan, and psychiatric evaluation.

CONCLUSION

Based on a systematic review of the present literature, any definitive statements regarding stroke lesion location and risk for depression are not yet substantiated. The authors suggest methodologies for future localization studies of poststroke depression.

Ultrasonic Spectroscopy Study of Flocculation and Shear-Induced Floc Disruption in Oil-in-Water Emulsions

Ultrasonic attenuation spectroscopy was used to study flocculation and shear-induced disruption of flocs in oil-in-water emulsions. The ultrasonic attenuation spectra (1 to 150 MHz) of a series of 10 wt% corn oil-in-water emulsions (r32 = 0.2 µm) were measured. Depletion flocculation was induced in the emulsions by adding different concentrations (0 to 0.2 wt%) of a nonadsorbing biopolymer (xanthan) to the aqueous phase. At low frequencies, the attenuation coefficient of the emulsions decreased with increasing flocculation due to overlap of the thermal waves generated by the droplets. These observations were in good agreement with a theory recently developed to account for the influence of droplet flocculation on the ultrasonic properties of emulsions. The ultrasonic technique was also used to monitor the breakdown of flocs under shear flow. The dependence of the ultrasonic properties of emulsions on flocculation means that ultrasonic attenuation spectroscopy can be used to study droplet interactions in concentrated emulsions. Copyright 1998 Academic Press.

Risperidone for the treatment of behavioral disturbances in dementia: a case series

The authors describe a series of 22 patients with dementia and behavioral disturbances, including agitation, aggression, delusions, and hallucinations, who were treated with risperidone. Risperidone, in low doses, was well tolerated; 50% of patients experienced significant improvement, although 50% experienced some extrapyramidal symptoms.

The management of behavioural disturbances in dementia: the role of serotonergic therapies

The behavioral and psychological signs and symptoms of dementia are common--serious disturbances that affect the quality of life for both patient and caregiver--and can lead to premature institutionalization. Recent research has focused on alterations in central serotonergic dysfunction as an important factor in the etiology of many of these disturbances, though numerous other neurotransmitter systems are also likely to be involved. The pharmacotherapy of behavioral disturbances is reviewed, focusing on serotonergic agents.

Determinants of interindividual variability and extent of CYP2D6 and CYP1A2 inhibition by paroxetine and fluvoxamine in vivo

Major depression may require antidepressant treatment for several years. This necessitates consideration of the long-term effects of antidepressants on multiple clinical endpoints. The antidepressants paroxetine and fluvoxamine are potent in vitro inhibitors of CYP2D6 and CYP1A2 isozymes, respectively. CYP2D6 and CYP1A2 are important for the clearance of 30 or more frequently used medications. Moreover, CYP1A2 also contributes to metabolism of 17beta-estradiol and metabolic activation of environmental procarcinogens (e.g., arylamines in cigarette smoke). The aim of this study was to assess the determinants of interindividual variability and extent of CYP2D6 and CYP1A2 inhibition during paroxetine and fluvoxamine treatment. Healthy volunteers and patients received caffeine (100 mg) and dextromethorphan (30 mg) at baseline and at steady state of paroxetine (10-20 mg/day, 5-74 days, N = 13) or fluvoxamine (50-100 mg/day, 5-43 days, N = 8). The caffeine metabolic ratio (CMR) and the log O-demethylation ratio (ODMR) of dextromethorphan in overnight urine were used as in vivo indices of the CYP1A2 and CYP2D6 isozyme activities, respectively. All subjects had an extensive metabolizer phenotype for CYP2D6. After fluvoxamine treatment, baseline CMR 5.1 +/- 1.4 (mean +/- SD) decreased to 2.7 +/- 1.1 (p < 0.01). Paroxetine did not have a significant effect on CMR (p > 0.05). In seven of eight subjects in the fluvoxamine group, posttreatment CMR was comparable with the minimum CMR value (2.0) attainable in nonsmoking healthy volunteers. After paroxetine treatment, log ODMR changed from a baseline value of -2.28 +/- 0.37 to -1.13 +/- 0.44, indicating significant inhibition of CYP2D6 (p < 0.001). Subjects' CYP2D6 phenotype did not change after paroxetine treatment. Fluvoxamine had no significant effect on log ODMR (p > 0.05). The extent of inhibition of CYP2D6 and CYP1A2 by paroxetine and fluvoxamine, respectively, displayed a positive correlation with baseline enzyme activity (p < 0.05). In addition, a negative association was found between the plasma paroxetine concentration and the CYP2D6 activity after paroxetine treatment (r = -0.47, p < 0.05). These data indicate that paroxetine and fluvoxamine treatment with minimum clinically effective doses significantly inhibit CYP2D6 and CYP1A2, respectively. The extent of inhibition of CYP2D6 by paroxetine and of CYP1A2 by fluvoxamine is dependent in part on the baseline enzyme activity. The interindividual variability in CYP2D6 inhibition by paroxetine can also be explained by variability in plasma paroxetine concentration. Most patients treated with fluvoxamine (50-100 mg/day) will reach population minimums for CYP1A2 activity. These results have potential implications for interindividual variability in the risk for drug-drug interactions mediated by CYP2D6 and CYP1A2 as well as for the disposition of 17beta-estradiol and environmental procarcinogens.

The Sunnybrook Stroke Study: a prospective study of depressive symptoms and functional outcome

BACKGROUND AND PURPOSE

To assess the prevalence of depressive symptoms, their clinical correlates, and the effects of depressive symptoms on stroke recovery, a relatively unselected, well-diagnosed cohort of consecutive stroke survivors was followed prospectively.

METHODS

Consecutive admissions to a regional stroke center who met World Health Organization and National Institute of Neurological Disorders and Stroke criteria for stroke were eligible. Subarachnoid hemorrhage and brain stem strokes were excluded. Patients underwent CT, single-photon emission CT, and standardized neurological and cognitive examinations at entry. At 3 months and 1 year after stroke, depressive symptoms were assessed with the Montgomery Asberg Depression Rating Scale (MADRS) and the Zung Self-Rating Depression Scale (SDS). Functional outcome was measured with the Functional Independence Measure, and handicap was assessed by the Oxford Handicap Scale.

RESULTS

We assessed 436 patients at entry (mean +/- SD age, 74.9 +/- 11.6 years). There were 150 patients available for assessment at 3 months and 136 at 1 year. Marked depressive symptoms were noted in 22% (SDS) to 27% (MADRS) at 3 months and 21% (SDS) to 22% (MADRS) at 1 year. Patents with marked depressive symptoms had more neurological impairment (P<.008), were more likely to be female (P<.05), and were more likely to have previous histories of depression (P<.03). There was no relationship between depressive symptoms and age, lesion volume, or side of lesion. Depressive symptoms were correlated with functional outcome (r = -.31, P<.0001) and handicap (r = .41, P<.0001) at 3 months and 1 year (r= -.28, P<.001; r = .35, P<.0001).

CONCLUSIONS

Depressive symptoms and functional outcome are correlated. In view of the prevalence of depressive symptoms in this population, diagnosis and treatment of depression are important in optimizing recovery.