Learning and recall in subjects at genetic risk for Alzheimer's disease

Deficits in delayed recall of learned information may be an early marker of Alzheimer's disease (AD). The apolipoprotein E E4 allele and a positive family history (FH) are both genetic risk factors for AD. The authors cross-sectionally compared performance on the California Verbal Learning Test (CVLT) in 153 prospectively recruited normal elderly subjects (mean age 67 years, mean MMSE=28) stratified by genetic risk into four groups (E4+/FH+, E4+/FH-, E4-/FH+, E4-/FH-). Neither FH nor E4 status affected performance, except on List B (a distraction word list), on which the FH+ group performed worse. The high-risk group (E4+/FH+) also performed worse on List B than the low-risk group (E4-/FH-) but did not differ on other measures. Memory impairments associated with genetic or family history risk may not manifest until the person is much closer to the onset age of AD.

Long-term effects of rivastigmine in moderately severe Alzheimer's disease: does early initiation of therapy offer sustained benefits?

Goals of the study included evaluating the long-term efficacy of rivastigmine in Alzheimer's disease (AD) patient categories stratified by baseline dementia severity, and post hoc investigation of particular benefits of early initiation of rivastigmine treatment in moderately severe AD. Both rivastigmine-treated groups (originally randomized to 1-4 or 6-12 mg/day) experienced significantly smaller declines in Alzheimer's Disease Assessment Scale-Cognitive subscale (ADAS-Cog) scores from baseline than the projected placebo group after 52 weeks. Patients receiving rivastigmine from Day 1 experienced significantly less decline compared with patients originally receiving placebo and then initiating rivastigmine treatment after a 6-month delay. Furthermore, cognitive benefits were more robust in patients with moderately severe disease compared with previous reports in mild to moderately severe AD. Findings suggest that early treatment with rivastigmine 6-12 mg/day is associated with sustained long-term cognitive benefits in patients with moderately severe AD. The results support the value of early treatment of AD patients, particularly those with moderately severe AD.

Health perception, pain, and disability as correlates of anxiety and depression symptoms in primary care patients

BACKGROUND

Anxiety and depression occur frequently, and recognition of their symptoms can be difficult because of comorbid medical conditions. The purpose of this study was to analyze the relations among symptoms, diagnoses, and severity of illness as indicators of anxiety and depression in primary care.

METHODS

This was an observational, cross-sectional study of adult patients in a large, academic family medicine clinic. Patients completed the Duke Health Profile, which measures health-related quality of life and screens for anxiety and depression. Providers recorded patient diagnoses and assessed severity of illness.

RESULTS

Patients with higher levels of anxiety and depression symptoms were more likely to have the diagnoses of headache, osteoarthritis, abdominal pain, and diabetes mellitus. These diagnoses, however, were no longer highly associated with anxiety and depression after controlling for age, sex, payer status, perceived health, pain, and disability. The indicators of high anxiety and depression symptom levels that persisted after controlling for all the other variables were female sex, low perceived health, more pain, and greater disability.

CONCLUSION

In a primary care setting, female sex, self-reported perceived health, pain, and disability were more predictive of anxiety and depression than any of the most prevalent medical illnesses. Primary care providers need to be knowledgeable about these health measures so they can recognize patients at risk for anxiety and depression regardless of their medical diagnoses.

Effect of Hypericum perforatum (St John's wort) in major depressive disorder: a randomized controlled trial

CONTEXT

Extracts of Hypericum perforatum (St John's wort) are widely used for the treatment of depression of varying severity. Their efficacy in major depressive disorder, however, has not been conclusively demonstrated.

OBJECTIVE

To test the efficacy and safety of a well-characterized H perforatum extract (LI-160) in major depressive disorder.

DESIGN AND SETTING

Double-blind, randomized, placebo-controlled trial conducted in 12 academic and community psychiatric research clinics in the United States.

PARTICIPANTS

Adult outpatients (n = 340) recruited between December 1998 and June 2000 with major depression and a baseline total score on the Hamilton Depression Scale (HAM-D) of at least 20.

INTERVENTIONS

Patients were randomly assigned to receive H perforatum, placebo, or sertraline (as an active comparator) for 8 weeks. Based on clinical response, the daily dose of H perforatum could range from 900 to 1500 mg and that of sertraline from 50 to 100 mg. Responders at week 8 could continue blinded treatment for another 18 weeks.

MAIN OUTCOME MEASURES

Change in the HAM-D total score from baseline to 8 weeks; rates of full response, determined by the HAM-D and Clinical Global Impressions (CGI) scores.

RESULTS

On the 2 primary outcome measures, neither sertraline nor H perforatum was significantly different from placebo. The random regression parameter estimate for mean (SE) change in HAM-D total score from baseline to week 8 (with a greater decline indicating more improvement) was -9.20 (0.67) (95% confidence interval [CI], -10.51 to -7.89) for placebo vs -8.68 (0.68) (95% CI, -10.01 to -7.35) for H perforatum (P =.59) and -10.53 (0.72) (95% CI, -11.94 to -9.12) for sertraline (P =.18). Full response occurred in 31.9% of the placebo-treated patients vs 23.9% of the H perforatum-treated patients (P =.21) and 24.8% of sertraline-treated patients (P =.26). Sertraline was better than placebo on the CGI improvement scale (P =.02), which was a secondary measure in this study. Adverse-effect profiles for H perforatum and sertraline differed relative to placebo.

CONCLUSION

This study fails to support the efficacy of H perforatum in moderately severe major depression. The result may be due to low assay sensitivity of the trial, but the complete absence of trends suggestive of efficacy for H perforatum is noteworthy.

Prevalence and impact of medical comorbidity in Alzheimer's disease

BACKGROUND

We examined the prevalence of comorbid medical illnesses in Alzheimer's disease (AD) patients at different severity levels. We also examined the effect of cumulative medical comorbidity on cognition and function.

METHODS

Analyses of data from 679 AD patients (Mini-Mental State Exam score range 0-30, mean +/- SD = 11.8 +/- 8) from 13 sites (four dementia centers assessing outpatients, four managed care organizations, two assisted living facilities, and three nursing homes) prospectively recruited using a stratification approach including dementia severity and care setting. Medical comorbidity was quantified using the Cumulative Illness Rating Scale-Geriatric.

RESULTS

Across patients, 61% had three or more comorbid medical illnesses. Adjusting for age, gender, race, and care setting, medical comorbidity increased with dementia severity (mild to moderate, p <.01; moderate to severe, p <.001). Adjusting for age, educational level, gender, race, and care setting, higher medical comorbidity was associated with greater impairment in cognition (p <.001) and in self-care (p <.001).

CONCLUSIONS

Despite the limitation of a cross-sectional design, our initial findings suggest that there is a strong association between medical comorbidity and cognitive status in AD. Optimal management of medical illnesses may offer potential to improve cognition in AD.

Quality of life in geriatric depression: a comparison of remitters, partial responders, and nonresponders

The authors examined patterns of improvement in quality of life (QOL) in elderly patients with recurrent major depression (MDD) after acute treatment. One hundred elderly (age 60-88 years) patients with recurrent MDD were randomized to receive either bupropion sustained-release (100 mg-300 mg/day) or paroxetine (10 mg-40 mg/day) for 6 weeks. Treatment with both paroxetine and bupropion was associated with improvements in QOL. Lower perceived Physical- and Social-Functioning QOL ratings at baseline were associated with lower treatment response. Improvement in depression symptom ratings correlated significantly with improvement in QOL on many domains, but accounted for less than one-quarter of the total variance. Remitters showed significantly (P<0.001) greater improvement than both Partial Responders and Nonresponders on various measures. Findings support the importance of treating elderly depressed patients to full remission to maximize impact on both emotional and physical QOL domains.

The spectrum of quality-of-life impairments in recurrent geriatric depression

BACKGROUND

Although recurrent major depression in elderly individuals is a disabling condition, only a few studies have systematically examined the magnitude and specificity of quality-of-life (QOL) impairments in such patients in comparison with matched controls or the elderly population.

METHODS

We examined the variations in QOL scores of 100 elderly (age range 60-88 years) patients with moderate to severe recurrent major depression and compared them with published elderly population norms. Disease-specific Quality of Life in Depression Scale (QLDS) and generic Medical Outcomes Short Form-36 Health Survey (SF-36) QOL ratings obtained at baseline were analyzed.

RESULTS

Compared with published elderly population norms, depressed subjects showed significant QOL impairments in five of eight baseline SF-36 items (p <.01). Women rated their QOL as worse than men on physical functioning and role physical (p <.01) and showed similar trends on all other QOL items. Compared with younger subjects, subjects aged older than 70 years reported lower QOL on the summary physical component (p <.01) and a trend for higher QOL on the summary mental component (p <.05) of the SF-36. Depression symptom ratings were correlated with some QOL measures, but accounted for less than 10% of the variance.

CONCLUSIONS

Despite limitations, such as a cross-sectional design and indirect comparisons with norms generated from another study, our findings confirm the disabling nature of recurrent late-life depression and the importance of targeting both depressive symptoms and broader QOL outcomes in intervention trials.

Treatment of social anxiety disorder with citalopram

Selective serotonin reuptake inhibitors (SSRIs) are used as treatment for generalized and specific social phobias (social anxiety disorders). The efficacy of citalopram, an SSRI, for the treatment of social anxiety disorders has not yet been fully evaluated. These cases suggest that citalopram may be an effective treatment for social anxiety disorder (social phobia). These cases are consistent with two other published reports with citalopram from outside the US. Randomized controlled studies are warranted.

Olanzapine-associated severe hyperglycemia, ketonuria, and acidosis: case report and review of literature

Olanzapine has been associated with insulin resistance and new-onset diabetes mellitus. A 27-year-old African-American man developed new-onset severe hyperglycemia-glucose 1240 mg/dl, with ketonuria and acidosis, but no weight gain-2 years after starting olanzapine. Although his diabetes was stabilized with insulin, his family had difficulty monitoring his therapy, and insulin was discontinued. Subsequent monotherapy with pioglitazone stabilized the patient's glucose levels, allowing him to continue taking olanzapine. Health care professionals should be aware of links between olanzapine and diabetes mellitus and of the potential for delayed recognition of complications associated with diabetes in patients who are psychotic. Insulin poses additional problems because families of patients with schizophrenia have to deal with compliance and risk of accidental or suicidal overdose. This case and others described in the literature illustrate such dilemmas and highlight the need to further study links connecting diabetes, insulin resistance, and olanzapine. Further research to determine proportionality and risk differences among various atypical antipsychotics also is warranted.

The Alzheimer's Disease Assessment Scale: evaluation of psychometric properties and patterns of cognitive decline in multicenter clinical trials of mild to moderate Alzheimer's disease

PURPOSE

To evaluate the psychometric properties and patterns of decline on the total score and item scores of the cognitive subscale of the Alzheimer's Disease Assessment Scale (ADAS-Cog) in patients with Alzheimer Disease (AD).

METHODS

We analyzed data from 536 AD outpatients randomized to the placebo group in two identical 26-week multicenter drug trials.

RESULTS

Mean deterioration at week 26 on the ADAS-Cog total score for subjects with moderate dementia was 84% greater than that for those with milder severity ( p < 0.001). After adjusting for this effect, age ( p = 0.015) and educational level ( p = 0.01) also predicted cognitive decline. In a model, absolute change for most individual ADAS items was less than 10% of the possible change, and it was generally smaller than one-third of the standard deviation of the measure. Measurement error variability was greatest for word recognition and the "placebo" effect was greatest for word recall. Variability increased with trial duration in a model.

CONCLUSIONS

There is a relationship between baseline severity and magnitude of cognitive decline. In 6-month trials, measurement error makes a substantial contribution to the variance in ADAS-Cog change scores. Sensitivity to intervention effects will therefore depend both on the variability and magnitude of change. Such data must be considered when designing future trials to minimize measurement error variability and increase sensitivity for specific populations.

Bupropion SR in the naturalistic treatment of elderly patients with major depression

INTRODUCTION

Bupropion immediate release (IR) and bupropion sustained release (SR) are frequently used to treat geriatric depression, as they have few cardiovascular, gastrointestinal and sexual adverse effects. We sought to examine the efficacy and dosing patterns of bupropion in a naturalistic cohort of elderly subjects with major depression (MD).

METHODS

31 elderly ( > 60 years) patients with unipolar MD (DSM-IV) who were enrolled in Duke's Mental Health Clinical Research Center for the Study of Depression in Later Life were prescribed bupropion SR or IR, alone or in combination with other antidepressant agents, for 12 weeks. Montgomery-Asberg depression rating scale (MADRS) scores and clinical global impression (CGI) severity scores were used to define response.

RESULTS

74% (23/31) of the sample were responders (MADRS < 15) and 53% (16/30) achieved a partial (CGI = 2) or complete (CGI = 1) remission of MD at week 12. Among patients treated with bupropion SR monotherapy, the mean (range) maximal daily dose achieved was 240 mg (150-400 mg). Among those treated with bupropion IR, the mean (range) maximum daily dose achieved was 258 mg (150-450 mg). In subjects on monotherapy, 67% (10/15) of MD subjects were responders (MADRS < 15) and 50% (7/14) achieved full or partial remission. Response rates did not differ statistically among those with high and low medical comorbidity.

CONCLUSIONS

In this naturalistic 12-week study, geriatric MD patients with high and low medical comorbidity responded well to bupropion and bupropion SR. In elderly patients, four to eight week acute treatment periods may be insufficient. Our findings suggest that nearly 50% of elderly depressed subjects at a tertiary center may need combination therapy over the course of their illness. Controlled randomized studies to establish the long-term efficacy and optimal dose of the newer antidepressants in geriatric depression are urgently needed.

Contemporary management of comorbid anxiety and depression in geriatric patients

Anxiety and depression in elderly people are major public health problems in the United States. Recognition and treatment of these conditions will likely gain more attention in the next 30 to 50 years because of the projected growth of the geriatric population. As in many younger patients, the most common presentation of anxiety in elderly patients is comorbid anxiety and depression. Although age is not a risk factor for either anxiety or depression, factors associated with aging--such as increased medical burdens and loss of independence--are substantial risk factors for development of these conditions. Moreover, there is a close association in older people between untreated mental illness and exacerbation of physical illness. Some of the newer antidepressants are more appropriate long-term options for the treatment of comorbid anxiety and depression than either benzodiazepines or tricyclic antidepressants. The newer antidepressants can decrease symptoms, improve quality of life, and potentially promote healthier outcomes in geriatric patients who have comorbid anxiety and depression and/or comorbid mental and physical illness.

Magnetic resonance spectroscopy in Alzheimer's disease: focus on N-acetylaspartate

This paper reviews published post-mortem brain and in-vivo proton magnetic resonance spectroscopy (1H-MRS) studies in Alzheimer's disease (AD) and focuses on the emerging role of N-acetylaspartate (NAA) as a prognostic marker of neuronal function. Post-mortem brain studies have reported significantly lower NAA levels in AD brains than in control brains, and some have correlated the low levels with neuropathological findings (i.e. amyloid plaques and neurofibrillary tangles). Similarly, almost all published in-vivo studies have reported lower NAA levels in AD patients compared to elderly controls. While some studies have found changes in metabolite levels that were considered useful for the diagnosis of AD, most have found that 1H-MRS provided little or no advantages over other, more common diagnostic tools. Instead, recent studies in AD and other neuropsychiatric disorders suggest that NAA may be more useful as a prognostic marker for monitoring neurodegeneration, stabilization, or improvement, and for evaluating therapeutic response to novel drugs.

Hippocampal abnormalities in depression

A quantitative magnetic resonance imaging study of regional brain T1 spin-lattice relaxation times in 29 normal volunteers and in 20 patients with major depression revealed significantly shortened T1 relaxation times for the hippocampus in depressed patients. These differences were particularly prominent in elderly depressed patients. T1 relaxation times are reflective of the content and macromolecular environment of tissue water protons; shorter hippocampal T1 values may reflect differences in the content or organizational properties of hippocampal water protons. These findings are consistent with several lines of evidence that have implicated a role for the hippocampus in the regulation of mood and in the pathophysiology of the stress response, and they suggest that major depression may be associated with biophysical tissue changes in the aging hippocampus.

Brain magnetic resonance imaging findings in ECT-induced delirium

A prolonged (interictal) but reversible delirium was induced by electroconvulsive therapy (ECT) in 10 of 87 (11%) elderly depressed patients. Brain magnetic resonance imaging (MRI) revealed several structural abnormalities, particularly basal ganglia and moderate to severe subcortical white-matter lesions, in the patients who developed delirium. These findings are consistent with several lines of data that have implicated the basal ganglia and subcortical white matter in the development of delirium from other causes and suggest that lesions in these areas may predispose one to developing an interictal delirium during a course of ECT.

Aging of the human corpus callosum: magnetic resonance imaging in normal volunteers

A brain magnetic resonance imaging (MRI) study of the corpus callosum in 36 normal volunteers, ages 26-79 years, revealed that age was positively correlated with the T1 spin-lattice relaxation time of the corpus callosum and was negatively correlated with the corpus callosum cross-sectional area. T1 relaxation times are sensitive to the content and macromolecular environment of tissue water, and variations in callosal T1 may reflect differences in the content or relaxation properties of callosal water. Such changes also potentially could occur secondary to alterations in the composition of callosal myelin. This study confirms and extends prior morphological studies that have reported age-related dimensional changes in the corpus callosum and, in addition, provides evidence of age-related biophysical tissue differences in the human corpus callosum.

Neuroanatomical substrates of depression in the elderly

The etiology of depression in the elderly is poorly understood. In this study, magnetic resonance imaging was used to evaluate the role of subcortical structures in the pathophysiology of depression in the elderly. Elderly depressed patients were found to have smaller caudate nuclei, smaller putaminal complexes and in increased frequency of subcortical hyperintensities compared with normal, healthy controls. These findings were more pronounced in patients with late-onset depression. Based on these findings, the authors discuss the role of the basal ganglia in the pathophysiology of depression in the elderly.

Clinical and treatment response characteristics of late-life depression associated with vascular disease: a pooled analysis of two multicenter trials with sertraline

1. The safety and efficacy of sertraline in the treatment of moderate-to-severe major depression in elderly outpatients, aged 60 years and older, with comorbid vascular disease was evaluated. 2. An analysis of the pooled results for the sertraline treatment group drawn from two prospective, randomized, double-blind studies (sertraline vs. fluoxetine, and sertraline vs. nortriptyline) was done. Patients were retrospectively categorized into one of 3 clinical groups: 1) patients with a current diagnosis of hypertension but no other past or present cardiovascular illness (HTN), 2) patients reporting a current or past history of cardiovascular illness, but excluding hypertension (VASC), and 3) patients with no hypertension, and no other comorbid vascular illness (NoVASC). Patients received 12-3. weeks of double-blind treatment with sertraline in flexible daily doses in the range of 50 - 150 mg (in the nortriptyline comparator trial) or 50 - 100 mg (in the fluoxetine comparator trial). 4. Sertraline treatment yielded comparable levels of response in all 3 groups (response criterion: CGI-much or very much improved) at treatment endpoint on both a completer analysis (HTN, 86%; VASC, 89%; NoVASC, 77%) and significantly higher response rates on a 12-week endpoint analysis (HTN, 74%; VASC, 69%; NoVASC, 58%; p < 0.05). Sertraline treatment was well-tolerated, with no between-group differences in rates of adverse events, or in discontinuation due to adverse events. Patients taking 5 or more concomitant medications showed no difference, when compared with patients taking none-or-one concomitant medication, either in rates of adverse events, or in discontinuation due to adverse events. 5. Sertraline was found to be a safe, well-tolerated, and effective as an antidepressant in elderly patients suffering from hypertension and other forms of vascular comorbidity.

Efficacy and safety of St. John's wort for the treatment of major depression

OBJECTIVE

Extracts of St. John's wort have been widely used in the treatment of depression. Our aim was to review information related to the efficacy and safety of St. John's wort as an antidepressant.

DATA SOURCES

Primary and review articles were identified by a search of Medline (1960 to February 2000) and through secondary sources.

STUDY SELECTION

All the articles identified from the data sources were evaluated and all relevant information was included in this review. The pharmacokinetics, mechanism of action, efficacy, side effects and drug interactions of St. John's wort have been examined in various studies.

CONCLUSION

St. John's wort is a promising investigational antidepressant, but the data are not yet sufficient to accept hypericum as a first line antidepressant preparation for treatment of depression. Besides the need for dose standardization and adequate trial lengths, there is a need for studies in severely depressed patients and long-term studies to assess the risk of relapse and recurrence.

Reboxetine: a selective norepinephrine reuptake inhibitor for the treatment of depression

OBJECTIVE

To review the pharmacology, pharmacokinetics, efficacy, and tolerability of reboxetine in the treatment of major depressive illness.

DATA SOURCES

A MEDLINE search restricted to English-language literature was conducted (1966 to July 1999). Abstracts and posters presented at meetings were also reviewed. DATA EXTRACTION/STUDY SELECTION: Studies currently available were conducted in Europe. Data from clinical trials were reviewed to gather information specific to efficacy analysis, pharmacokinetic parameters, tolerability profiles, and drug-drug interactions. Information on reboxetine was compared with other antidepressant therapies when appropriate data were available.

DATA SYNTHESIS

Reboxetine is a selective norepinephrine reuptake inhibitor shown to be an effective agent in the treatment of major depressive illness. In clinical trials, reboxetine was effective in decreasing mean total scores of the Hamilton Rating Scale for Depression in adult populations. Improvements were similar between reboxetine and desipramine and imipramine, as well as fluoxetine. Reboxetine is relatively well tolerated, with insomnia, sweating, constipation, and dry mouth being commonly reported adverse events. Hypotension and urinary hesitancy occur at lower rates than with the tricyclics, and compared with fluoxetine, reboxetine is associated with lower rates of nausea, somnolence, and diarrhea. Dosage adjustments may be appropriate in elderly patients and those with renal and hepatic impairment.

CONCLUSIONS

Reboxetine has received two letters of approval from the Food and Drug Administration for the treatment of major depression in adults. Upon completion of an additional US clinical study, reboxetine is likely to become a first-line agent in the management of depressive illness and a promising alternative for patients who have failed treatment with or do not tolerate serotonergic antidepressants.

A double-blind comparison of sertraline and fluoxetine in depressed elderly outpatients

BACKGROUND

There has been a paucity of well-designed studies comparing selective serotonin reuptake inhibitor (SSRI) medications in the treatment of depression in the elderly. This multicenter study was designed to examine the efficacy and safety of sertraline and fluoxetine in depressed elderly outpatients. A secondary objective was to examine the effects of SSRI treatment on quality of life and cognitive function.

METHOD

Two hundred thirty-six outpatients 60 years of age and older who met DSM-III-R criteria for major depressive disorder received 1 week of single-blind placebo before being randomly assigned to 12 weeks of double-blind, parallel-group treatment with flexible daily doses of either sertraline (range, 50-100 mg) or fluoxetine (range, 20-40 mg). Primary efficacy measures consisted of the 24-item Hamilton Rating Scale for Depression and Clinical Global Impressions scale ratings. Secondary outcome assessments included clinician- and patient-rated measures of depression symptoms and factors, cognitive functioning, and quality of life, as well as plasma drug concentrations, which were correlated with clinical response.

RESULTS

Both drugs produced a similarly positive response on the primary efficacy measures, with 12-week responder rates of 73% for sertraline and 71% for fluoxetine. Sertraline-treated patients showed statistically greater cognitive improvement on several measures. Both drugs were safe and well tolerated.

CONCLUSION

Data indicate that both drugs are effective antidepressants for the treatment of depressed elderly outpatients. Differences in cognitive performance effects deserve further investigation.

Hippocampal sulcal cavities on MRI: relationship to age and apolipoprotein E genotype

Hippocampal sulcal cavities are usually considered incidental findings on brain MRI. In a group of 92 elderly volunteers, the authors graded the number and size of hippocampal sulcal cavities with brain MRI to obtain a cavity score. Cavity scores increased with age, and were higher in subjects carrying the APOE epsilon4 or epsilon2 alleles than in subjects with the epsilon3/3 genotype. Age-related morphologic changes in the hippocampus may be mediated by the APOE genotype.

Current and future treatments for cognitive deficits in dementia

In this article, we primarily focus on the treatment approaches currently marketed and in advanced stages of development for Alzheimer's disease (AD). Amyloid plaques and neurofibrillary tangles remain the pathologic hallmarks of AD, and much progress has been made in unraveling the molecular biology of these changes. In addition, there is also intense research into inflammatory and oxidative mechanisms as well as vascular and neurochemical alterations in AD. Therapies targeted at these mechanisms are discussed.

Effect of Bupropion SR on the Quality of Life of Elderly Depressed Patients With Comorbid Medical Disorders

BACKGROUND: There is a need for additional studies of the quality of life (QOL) of elderly depressed subjects with medical comorbidity. METHOD: We conducted an 8-week, open trial of bupropion sustained release (SR) in 18 elderly (60-81 years) subjects with DSM-IV major depressive disorder and one or more serious medical illnesses (e.g., congestive heart failure, type 1 diabetes mellitus, irritable bowel syndrome) with a week-12 follow-up interview. The intent-to-treat method with the last observation carried forward was used to analyze depression and QOL measures. Dosing was initiated at 100 mg once daily and increased at weekly intervals to a maximum of 150 mg twice daily as clinically indicated. RESULTS: Bupropion SR treatment was associated with reductions in Clinical Global Impressions-Severity of Illness scale (p <.0001) score and in the 17-item Hamilton Rating Scale for Depression (HAM-D) total score (p <.0001). QOL as measured by the Medical Outcomes Study Short Form-36 (SF-36) also tended to improve with treatment. The SF-36 "mental health" (p <.01) and "social functioning" (p <.0006) domains improved significantly by week 4. "Vitality" (p <.03) improved significantly by week 12. On the HAM-D, statistically significant improvement was noted on "depressed mood" (p <.0001), "feelings of guilt" (p <.01), "work and activities" (p <.001), "hypochondriasis" (p <.02), and "insomnia" (p <.01) at week 8. The mean dose of bupropion SR at endpoint was 222 mg/day, and the drug was relatively well tolerated. Two subjects dropped out owing to adverse events and 2 owing to other reasons. No drug-drug interactions occurred. CONCLUSION: These data suggest that bupropion SR is well tolerated and may improve depression, insomnia, somatic symptoms, work functioning, and certain quality-of-life measures in elderly depressed subjects with medical disorders. A randomized, placebo-controlled study is warranted to confirm these promising findings.

Effects of exercise training on older patients with major depression

BACKGROUND

Previous observational and interventional studies have suggested that regular physical exercise may be associated with reduced symptoms of depression. However, the extent to which exercise training may reduce depressive symptoms in older patients with major depressive disorder (MDD) has not been systematically evaluated.

OBJECTIVE

To assess the effectiveness of an aerobic exercise program compared with standard medication (ie, antidepressants) for treatment of MDD in older patients, we conducted a 16-week randomized controlled trial.

METHODS

One hundred fifty-six men and women with MDD (age, > or = 50 years) were assigned randomly to a program of aerobic exercise, antidepressants (sertraline hydrochloride), or combined exercise and medication. Subjects underwent comprehensive evaluations of depression, including the presence and severity of MDD using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria and Hamilton Rating Scale for Depression (HAM-D) and Beck Depression Inventory (BDI) scores before and after treatment. Secondary outcome measures included aerobic capacity, life satisfaction, self-esteem, anxiety, and dysfunctional cognitions.

RESULTS

After 16 weeks of treatment, the groups did not differ statistically on HAM-D or BDI scores (P = .67); adjustment for baseline levels of depression yielded an essentially identical result. Growth curve models revealed that all groups exhibited statistically and clinically significant reductions on HAM-D and BDI scores. However, patients receiving medication alone exhibited the fastest initial response; among patients receiving combination therapy, those with less severe depressive symptoms initially showed a more rapid response than those with initially more severe depressive symptoms.

CONCLUSIONS

An exercise training program may be considered an alternative to antidepressants for treatment of depression in older persons. Although antidepressants may facilitate a more rapid initial therapeutic response than exercise, after 16 weeks of treatment exercise was equally effective in reducing depression among patients with MDD.

Magnetic resonance assessment of cerebral perfusion in depressed cardiac patients: preliminary findings

OBJECTIVE

The authors investigated the links between depression, cardiac disease, and microcirculatory cerebral blood flow (CBF).

METHOD

A magnetic resonance imaging technique based on arterial spin tagging was used to estimate microcirculatory CBF in depressed (N = 5) and comparison (N = 14) elderly subjects with coronary artery disease. Signal intensity ratios corresponding to relative microcirculatory CBF were calculated for four regions on two axial images through the upper and lower halves of the lateral ventricles.

RESULTS

On the superior image, estimates of microcirculatory CBF were statistically significantly lower on the left side in the depressed subjects than in the nondepressed group. When the ratios in the superior and inferior images were averaged, the depressed subjects had lower values for both left periventricular regions of interest and the parietal region.

CONCLUSIONS

Despite the small study group and indirect estimates of blood flow, these preliminary findings suggest that a relative cerebral hypoperfusion may underlie depression in elderly cardiac patients.

Defining meaningful change in Alzheimer's disease trials: the donepezil experience

Regulatory guidelines in the US and Europe generally require that a drug specifically indicated for treating Alzheimer's disease (AD) must demonstrate an effect upon the core manifestations of dementia. Progressive cognitive and functional losses are the cardinal features of AD. In the US, current guidelines require that new AD treatments show effectiveness on performance-based measures of cognition and on clinician-rated global assessments. Improvement in function is also emphasized in the European guidelines. The primary instruments that have been used to evaluate changes in cognition and global function in most recent AD trials are the cognitive subscale of the Alzheimer's Disease Assessment Scale and a version of the Clinician's Interview Based Impression of Change, respectively. The results from three pivotal trials investigating the acetylcholinesterase inhibitor, donepezil, are used to demonstrate the way in which these tools are used, how to interpret the data they provide, and to determine their overall value in ascertaining efficacy in clinical practice.

Current status of antioxidant therapy for Alzheimer's Disease

Accumulating evidence from preclinical and clinical studies supports the hypothesis that oxidative stress may be associated with the onset and progression of Alzheimer's Disease (AD). Antioxidant therapies are being promoted in the lay press to enhance mental functions and delay cognitive losses with aging. An increasing number of physicians are also recommending antioxidant therapies, such as high dose vitamin E, for subjects with AD and other neurodegenerative disorders. High dose vitamin E, ginkgo biloba, and selegiline are three putative antioxidants that have been tested in randomized multicenter trial conditions in the US. This paper summarizes the oxidative stress hypothesis of AD and reviews the strengths and limitations of published antioxidant studies in AD in relation to the role of such therapies in practice.

Early recognition of Alzheimer's disease: what is consensual? What is controversial? What is practical?

Alzheimer's disease is often unrecognized or misdiagnosed in its early stages. Despite the lack of curative treatments, there are compelling reasons why early recognition of Alzheimer's disease may offer substantial benefits. Early evaluation and diagnosis may offer opportunities to enhance patient safety, allow families to plan for the future, provide family education and support, and initiate the best treatment before more substantial neuronal loss occurs. Barriers to early diagnosis include failure of family or physicians to recognize the existence or importance of cognitive/functional changes and/or misperceptions regarding diagnostic requirements and treatment capabilities. There is consensus that high diagnostic accuracy can be achieved clinically, even by nonspecialists, using established criteria and practice parameters. Population-based screening programs for the elderly, genetic testing, yield of routine neuroimaging studies, and the diagnostic value of certain molecular markers remain controversial. This review highlights practical issues related to the initial clinical evaluation and differential diagnosis of Alzheimer's disease.

Combination therapy for early Alzheimer's disease: what are we waiting for?

The practical pharmacological approaches currently available to palliate the cognitive and functional losses in early Alzheimer's disease (AD) include cholinesterase inhibitors (ChEI), antioxidants (e.g., vitamin E), anti-inflammatory agents, estrogen, seligiline, vasoactive agents, and ginkgo biloba. Reviewing available data on these therapies and using models from medical illnesses such as cancer and hypertension, we highlight the urgent need for evaluating combination therapies in early AD.

The Alzheimer's Disease Assessment Scale: patterns and predictors of baseline cognitive performance in multicenter Alzheimer's disease trials

The cognitive subscale of the Alzheimer's Disease Assessment Scale (ADAS-Cog) is used as an efficacy measure in clinical drug trials of Alzheimer's disease (AD). We used data from 1,648 AD participants in two identical 26-week multicenter drug trials to examine the distribution of baseline ADAS-Cog scores in relation to selected demographic and clinical variables, Mini-Mental State Exam (MMSE), Global Deterioration Scale (GDS), and Geriatric Evaluation by Relative's Rating Instrument (GERRI) scores. At baseline, the mean (+/-SD) MMSE score was 18 +/- 4, the ADAS-Cog score was 28 +/- 11, and most subjects were in GDS stage 4 or 5. The ADAS-Cog score was statistically significantly correlated with MMSE (R = -0.76, p < 0.0001) and GERRI (R = 0.40, p < 0.0001) total scores. Correlations among the ADAS-Cog items ranged from 0.19 to 0.59 and all were statistically significant (p < 0.0001). In a multiple regression model, younger age, male gender, older age at onset of dementia, use of concurrent estrogen, and use of concurrent anti-inflammatory agents were statistically significantly associated with superior cognitive performance. We also present data on the distribution of ADAS-Cog scores in relation to subjects' age, level of education, MMSE score, and GDS stage. Because age, MMSE score, and GDS stage (and not the ADAS-Cog) are commonly used to select subjects for AD clinical trials, our data should improve the ability of sponsors to predict ADAS-Cog scores of the subjects in their trials on the basis of the inclusion criteria used. Our data also suggest that age, gender, age at onset of dementia, level of education, and use of estrogen (in women) or anti-inflammatory drugs are related to cognitive abilities in AD. Further studies are needed to assess how and when cognitive differences related to these variables arise.

Memory, language, and praxis in Alzheimer's disease: norms for outpatient clinical trial populations

The cognitive subscale of the Alzheimer's Disease Assessment Scale (ADAS-Cog) is designed specifically to assess memory, language, and praxis dysfunctions characteristic of Alzheimer's disease (AD). In this report, we use data from 1,648 AD participants in two identical 26-week multicenter drug trials to derive clinical trial population-based norms for ADAS-Cog subtest scores. All 11 ADAS-Cog item scores were sensitive to differences in dementia severity judged either by baseline Mini-Mental State Exam (MMSE) scores or by Global Deterioration Scale (GDS) stage of dementia. Using ADAS-Cog subtest scores alone, 85 percent of GDS 4 subjects and 69 percent of GDS 5 subjects could be classified correctly. In a stepwise discriminant analysis, orientation was the item with the greatest discriminatory power between subjects with GDS 4 and GDS 5 stages of dementia. ADAS-Cog subtest scores also varied by age, gender, educational level, and concurrent use of anti-inflammatory drugs or estrogen (in women). Such normative data may facilitate the selection of appropriate outcome measures to investigate differential treatment effects on specific cognitive domains or in specific AD subpopulations.

Neurobiology of chronic fatigue syndrome

1. Chronic fatigue syndrome (CFS) is characterized by a new onset of significant fatigue for a period of six months or longer usually following an infection, injury or period of high stress. 2. The exact etiology of CFS is not known and a diagnostic test is not available. Hence, the diagnosis is made by exclusion of other explanations for the patient's symptoms and by meeting the CDC research case definitions. Early studies supported an infectious or immune dysregulation hypothesis for the pathophysiology of CFS. 3. Subsequent studies documented that neurological, affective and cognitive symptoms also occur at high rates in CFS patients. Neuropsychological, neuroendocrine studies and brain imaging have now confirmed the occurrence of neurobiological abnormalities in most patients with CFS. 4. In this article, the authors review these findings in relation to the clinical neurobiology of CFS and their potential relevance to biological psychiatry.

Cognitive performance on the Alzheimer's Disease Assessment Scale: effect of education

The cognitive subscale of the Alzheimer's Disease Assessment Scale (ADAS-Cog) is used to monitor disease progression and treatment efficacy in clinical trials of Alzheimer's disease (AD). Using data from a 12-week drug trial, we retrospectively studied the effect of education on ADAS-Cog performance in a group of 444 patients with AD. The effect of education was statistically significant on baseline ADAS-Cog total scores. This effect remained statistically significant after controlling for age, gender, and dementia severity. Education effects were also statistically significant at week 12 for ADAS-Cog total and 10 of 11 subitem scores in 138 AD patients in the placebo arm of the trial. Post hoc analysis showed that non-high school graduates performed worse than those with greater educational levels across a broad range of cognitive domains. Our results, in conjunction with reports linking lower educational level with a higher risk for AD, suggest that educational level of patients be given consideration in the design and interpretation of cognitive tests in AD drug trials.

Emergency department patterns in psychiatric visits during the holiday season

STUDY OBJECTIVE

To determine the prevalence of psychopathology during the holiday season and which subpopulations are at greatest risk for holiday decompensation.

DESIGN

A retrospective analysis of emergency department records.

SETTING

ED of a university-affiliated hospital located in a mixed urban-agricultural catchment area in North Carolina.

PARTICIPANTS

Eight thousand seven hundred fifty-six patient visits to the ED, with subsequent triage for psychiatric evaluation, for a 6-year period (1987 to 1993), were analyzed.

RESULTS

We observed seasonal patterns in visits, with a general decrease in visits preceding holidays followed by an increase afterward. Substance abusers, men, and black patients were more likely to visit the ED than expected, particularly during the weeks surrounding Christmas.

CONCLUSION

These results support the existence of a "Christmas effect" on ED visitations by patients with psychiatric symptoms. Understanding of these patterns may help emergency physicians predict the seasonal variation of such patient visits and apply preventive measures accordingly.

Proton spectroscopy of human brain: effects of age and sex

1. The present study was done to assess the brain metabolites measured by proton magnetic resonance spectroscopy (MRS) in normal individuals. 2. Proton spectroscopy STEAM voxel technique with chemical shift imaging was used to provide localized metabolic information from the brains of 34 normal volunteers (15 males) between the ages of 21 and 75 years. 3. Choline, Creatine and N-acetyl aspartate (NAA) was lower in white matter than gray matter. Choline/NAA and choline/creatine ratios were also lower in white matter. The choline, creatine and NAA were lower in older subjects in the voxel representing cortical and subcortical gray matter. There were no differences between males and females. 4. This preliminary study suggests that age matching is essential for comparative studies of disease states using proton MRS.