Depressive symptoms in Alzheimer's disease: natural course and temporal relation to function and cognitive status

Cognitive decline in patients with dementia as a function of depression

OBJECTIVE

There is evidence that major depression increases the risk for dementia, but there is conflicting evidence as to whether depression may accelerate cognitive decline in dementia. The authors tested the hypothesis that decline in cognitive function over time is more pronounced in patients with dementia with comorbid depression, when compared with patients with dementia without depression history.

DESIGN

Prospective, longitudinal cohort study of aging.

SETTING

Nursing home.

PARTICIPANTS

Three hundred thirteen elderly nursing home residents (mean age at baseline: 86.99 years, standard deviation = 6.7; 83.1% women). At baseline, 192 residents were diagnosed with dementia, and another 27 developed dementia during follow-up. Thirty residents suffered from major depression at any point during the study, and 48 residents had a history of depression.

MEASUREMENTS

The authors measured cognitive decline using change in Mini-Mental State Examination (MMSE) scores over up to 36 months. The authors calculated multilevel regression models to estimate the effects of age, gender, education, dementia status, depression, depression history, and an interaction between dementia and depression, on change in MMSE scores over time.

RESULTS

Beyond the effects of age, gender, and education, residents showed steeper cognitive decline in the presence of dementia (β = -13.69, standard error = 1.38) and depression (β = -4.16, SE = 1.2), which was further accelerated by the presence of both depression and dementia (β = -2.72, SE = 0.65).

CONCLUSIONS

In dementia, the presence of depression corresponds to accelerated cognitive decline beyond gender and level of education, suggesting a unique influence of depression on the rate of cognitive decline in dementia.

Impact of depressive symptoms on outcome of Alzheimer's disease

There is no consensus in the medical literature about the impact of depressive symptoms on the evolution of Alzheimer’s disease (AD).

Persistent depressive symptoms and cognitive function in late midlife: the Whitehall II study

OBJECTIVE

Depression has been widely linked to poor cognition and dementia in the elderly. However, comorbidity at older ages does not allow an assessment of the role of mental health as a risk factor for cognitive outcomes. We examined the association between depressive symptoms, measured 6 times over an 18-year period, and cognitive deficits in late midlife.

METHOD

Of the 10,308 participants in the Whitehall II study, 4,271 men and women (aged 35-55 years at baseline) were followed up for 18 years, during which depressive symptoms were assessed 6 times using the General Health Questionnaire depression subscale. The follow-up was from 1985-1988 to 2002-2004. Cognition was assessed at the most recent wave (2002-2004, mean age 61 years, range 50-74 years) using 6 tests: memory, reasoning, vocabulary, 2 tests of verbal fluency, and the MMSE (Mini Mental State Examination). Cognitive deficit was defined as MMSE score <28 and performance in the worst sex-specific quintile for the other tests.

RESULTS

History of depressive symptoms, once or more in the 6 times assessed, had a weak association with some of the cognitive tests. However, in analysis adjusted for sociodemographic variables, diabetes, coronary heart disease, hypertension, stroke, and antidepressant use, persistent depressive symptoms (4-6 times) were associated with cognitive deficits on all tests: memory (OR=1.91; 95% CI, 1.36-2.67), reasoning (OR=1.60; 95% CI, 1.15-2.20), vocabulary (OR=1.75; 95% CI, 1.27-2.41), phonemic fluency (OR=1.40; 95% CI, 1.00-1.94), semantic fluency (OR=1.68; 95% CI, 1.20-2.35), and the MMSE (OR=1.76; 95% CI, 1.25-2.50).

CONCLUSIONS

Our data show that depressive episodes tend to persist in some individuals, and these individuals are at a greater risk of cognitive deficits in late midlife.

Temporal course of depressive symptoms during the development of Alzheimer disease

OBJECTIVE

To characterize change in depressive symptoms before and after the onset of dementia in Alzheimer disease (AD).

METHOD

We used data from the Chicago Health and Aging Project, a longitudinal cohort study of risk factors for AD in a geographically defined population of old people. Two subsets were analyzed. In 357 individuals who developed incident AD during the study, self-report of depressive symptoms (Center for Epidemiologic Studies Depression Scale) was obtained at 3-year intervals for a mean of 8 to 9 years. In 340 individuals who agreed to annual data collection, informant report of depressive symptoms (Hamilton Depression Rating Scale) was obtained for a mean of 3 years after a diagnosis of AD (n = 107), mild cognitive impairment (n = 81), or no cognitive impairment (n = 152).

RESULTS

The incident AD group reported a barely perceptible increase in depressive symptoms during 6 to 7 years of observation before the diagnosis (0.04 symptoms per year) and no change during 2 to 3 years of observation after the diagnosis except for a slight decrease in positive affect. In those with annual follow-up, neither AD nor its precursor, mild cognitive impairment, was associated with change in informant report of depressive symptoms during a mean of 3 years of observation.

CONCLUSION

Depressive symptoms show little change during the development and progression of AD to a moderate level of dementia severity.

The Functional Transitions Model: Maximizing Ability in the Context of Progressive Disability Associated with Alzheimer's Disease

The Functional Transitions Model (FTM) integrates the theoretical notions of progressive functional decline associated with Alzheimer's disease (AD), excess disability, and transitions occurring intermittently along the trajectory of functional decline. Application of the Functional Transitions Model to clinical practice encompasses the paradox of attempting to minimize excess disability while anticipating the progressive functional decline associated with AD. It is suggested that times of functional transition are times of decision making and opportunities for interdisciplinary collaboration to identify and minimize excess disability, for revision of goals and expectations, and for provision of support to patients and caregivers. The model also is applicable as a conceptual framework for education and research.

The effect of anxiety and depression on decline of memory function in Alzheimer's disease

BACKGROUND

Patients with Alzheimer's disease (AD) and concomitant atrophy of the hippocampus may be extra vulnerable to the consequences of psychological distress, leading to greater decline in memory function. The present study investigated whether symptoms of anxiety and depression predict decline of memory function in elderly people diagnosed with early stage AD.

METHODS

A sample of 44 elderly people diagnosed with early stage AD was tested on their memory function, anxiety and depression and confounding variables with one year follow-up. Episodic memory was measured with a modified Dutch version of the Auditory Verbal Learning Test (AVLT) which measures learning and recall abilities. Linear regression analyses were used to investigate the association between anxiety and depressive symptoms and decline of memory function.

RESULTS

Anxiety symptoms predicted a smaller decline in learning on the AVLT. Anxiety symptoms did not predict decline on the recall of the AVLT. No association was found between depressive symptoms and decline in either learning or recall of the AVLT.

CONCLUSIONS

In early AD, symptoms of anxiety and depression generally seem to be mild, and do not accelerate decline of memory function over time. On the contrary, anxiety symptoms were found to predict a smaller decline in memory function.

Seizures in Alzheimer disease: who, when, and how common?

BACKGROUND

Transient symptoms in Alzheimer disease (AD) are frequent and include seizures, syncope, and episodes of inattention or confusion. The incidence of seizures in AD and predictors of which patients with AD might be more predisposed to them is based primarily on retrospective studies and is not well established.

OBJECTIVE

To determine the incidence and predictors of new-onset unprovoked seizures.

DESIGN

Prospective cohort study.

SETTING

Three academic centers. Patients Four hundred fifty-three patients with probable AD observed prospectively from mild disease stages since 1992. Main Outcome Measure Informant interviews every 6 months included questions about whether the patient had a seizure (convulsion, fainting, or "funny" spell) and whether diagnosis or treatment for epilepsy or seizure was made. Two epileptologists independently retrospectively reviewed all available medical records for 52 patients with positive responses to either of these questions, and using a specific checklist form, events were diagnosed as to whether they were unprovoked seizures (intrarater concordance, kappa = 0.67). Diagnosis of unprovoked seizures constituted the event in survival analyses. Potential predictors included sex, age, race/ethnicity, educational achievement, duration of illness, baseline cognition and function, depression, medical comorbidities, and time-dependent use of cholinesterase inhibitors and neuroleptic agents, apolipoprotein E genotype, and previous electroencephalographic findings.

RESULTS

Over the course of 3518 visit-assessments (per patient: mean, 7.8; maximum, 27), 7 patients (1.5%) developed seizures. Younger age was associated with higher risk (hazard ratio, 1.23; 95% confidence interval, 1.08-1.41; P = .003 for each additional year of age) of seizure incidence. No other predictor was significant. The overall incidence of seizures was low (418 per 100 000 person-years of observation) although significantly higher than expected for idiopathic unprovoked seizures in similar age ranges of the general population (hazard ratio, 8.06; 95% confidence interval, 3.23-16.61).

CONCLUSIONS

Unprovoked seizures are uncommon in AD, but they do occur more frequently than in the general population. Younger age is a risk factor for seizures in AD.

Screening for Alzheimer's dementia at age 78 with short psychometric instruments

BACKGROUND

To date, no single instrument has proved to be adequate for screening for Alzheimer's dementia (AD). The aim of this study was to identify a combination of instruments which were highly sensitive for screening late onset AD.

METHODS

Subjects were drawn from the Vienna TransDanube Aging (VITA) study. This is an interdisciplinary, longitudinal community-based cohort study of the 21st and 22nd district of Vienna (Austria). Data refer to the cohort of 478 individuals at age 78 who took part in the first follow-up investigation of the VITA study. The psychometric instruments which were investigated were: the Ten-Point Clock Test, the Human-Figure Drawing Test, a Delayed Selective Reminding Test, Naming, the Trail Making Test-B, and Verbal Fluency. Further instruments were the Pocket Smell Test, and Subjective Memory Complaints. Data were analyzed using logistic regression analyses and cross validation.

RESULTS

A combination of the Delayed Selective Reminding Test and Verbal Fluency was best for screening AD (R2 = 0.38, main model). An area under the ROC curve of 0.829 was reached. This model discriminated between subjects with incident AD and subjects who did not have incident AD with a sensitivity of 91% and a specificity of 56%.

CONCLUSION

The combination of an episodic memory test and a test of verbal fluency was an effective way of screening for AD.

Depressive symptoms, vascular risk factors and mild cognitive impairment. The Italian longitudinal study on aging

AIMS

We evaluated the impact of depressive symptoms on the rate of incident mild cognitive impairment (MCI) after a 3.5-year follow-up, and we assessed the interaction between depressive symptoms and vascular risk factors for incident MCI.

METHODS

A total of 2,963 individuals from a sample of 5,632 65- to 84-year-old subjects were cognitively and functionally evaluated at the 1st and 2nd surveys of the Italian Longitudinal Study on Aging, a prospective cohort study with a 3.5-year follow-up. MCI and dementia were classified using current clinical criteria. Depressive symptoms were measured with the Geriatric Depression Scale.

RESULTS

Among the 2,963 participants, 139 prevalent MCI cases were diagnosed at the 1st survey. During the 3.5-year follow-up, 105 new events of MCI were diagnosed. We did not observe any significant association between depressive symptoms and incident MCI (RR = 1.25, 95% CI = 0.85-1.84, chi(2) = 1.30, p < 0.25). No sociodemographic variables or vascular risk factors modified the relationship between depressive symptoms and incident MCI.

CONCLUSION

In our population, depressive symptoms were not associated with the rate of incident MCI. Our findings did not support a role of sociodemographic variables or vascular risk factors in the link between depressive symptoms and incident MCI.

Differential association of concurrent, baseline, and average depressive symptoms with cognitive decline in older adults

OBJECTIVES

The impact of depressive symptoms on cognitive decline in older adults remains unclear due to inconsistent findings in the literature. It is also unclear whether effects of depressive symptoms on cognitive decline vary with age. This study investigated the effect of concurrent, baseline, and average depressive symptoms on cognitive functioning and decline, and examined the interactive effect of age and depressive symptoms on cognition.

DESIGN

Prospective observational design with examination of cognitive performance and depressive symptoms at 1- to 2-year intervals for up to 26 years.

SETTING

Baltimore Longitudinal Study of Aging, National Institute on Aging.

PARTICIPANTS

One thousand five hundred eighty-six dementia-free adults 50 years of age and older.

MEASUREMENTS

Scores over time on the Center for Epidemiologic Studies Depression Scale and measures of learning and memory, attention and executive functions, verbal and language abilities, visuospatial functioning, and general cognitive status.

RESULTS

Increased depressive symptoms were associated with poor cognitive functioning and cognitive decline in multiple domains. Concurrent, baseline, and average depressive symptoms had differential associations with cognition. Average depressive symptoms, a measure of chronic symptoms, seemed to show the most widespread effects on cognitive abilities. Effects of depressive symptoms on some frontal functions were greater with advancing age.

CONCLUSION

Depressive symptoms are associated with poor cognitive functioning and cognitive decline, particularly with advancing age. The widespread impact of average depressive symptoms on cognition suggests that clinicians should consider the chronicity of depressive symptoms when evaluating cognitive functioning in older adults.

Symptoms of anxiety and depression in the course of cognitive decline

BACKGROUND/AIMS

Anxiety and depression are common inpatients with cognitive decline and Alzheimer's disease (AD), and recognition and treatment of these symptoms can improve their quality of life. The present study investigates anxiety and depression in different phases of cognitive decline.

METHODS

The sample consisted of five groups of elderly people in different phases of cognitive decline; four from a community-based sample (Longitudinal Aging Study Amsterdam), and one group of elderly people diagnosed with AD. ANOVAs were performed to investigate group differences in the severity and prevalence of anxiety and depression, and comorbid anxiety and depressive symptoms.

RESULTS

The prevalence rates of anxiety, comorbid anxiety and depressive symptoms and depressive symptoms follow a pattern of an increasing prevalence as cognitive performance declines and a decrease in the prevalence when cognitive functioning is severely impaired. AD patients report fewest anxiety symptoms.

CONCLUSION

We found that the prevalence of anxiety symptoms, depressive symptoms and comorbid anxiety and depressive symptoms seems to increase in the early phase of cognitive decline, and decreases as cognitive functioning further declines. Elderly diagnosed with AD report less anxiety as expected, probably due to lack of insight caused by AD.

Frontotemporal dementia to Alzheimer's disease

Behavioral manifestations may dominate the clinical picture of the frontal variant of frontotemporal dementia (fv-FTD) for a long time before the appearance of true cognitive deficits. On the other hand, a deficit in the episodic memory domain represents the main manifestation of Alzheimer's disease (AD), Many behavioral disorders have been described in the clinical course of both FTD and AD; however, apathy and personality changes characterize frontal dementias, while depression dominates in AD, at least in the earlier stages. Depending on the distribution of neural damage, different patterns of noncognitive manifestations may be expected in different subtypes of FTD, Recent research on the social cognition deficit in FTD has offered new insights into the relationship between cognition and behavior, suggesting that some aspects of the behavioral changes in dementia may be generated by impairment in this domain.

A promoter polymorphism in the monoamine oxidase A gene is associated with the pineal MAOA activity in Alzheimer's disease patients

BACKGROUND

Monoamine oxidase A (MAOA) is involved in the pathogenesis of mood disorders and Alzheimer's disease (AD). MAOA activity and gene expression have been found to be up-regulated in different brain areas of AD patients, including the pineal gland. Increased pineal MAOA activity might contribute to the reduced pineal melatonin production in AD. A promoter polymorphism of a variable number tandem repeats (VNTR) in the MAOA gene shows to affect MAOA transcriptional activity in vitro.

METHODS

Here we examined in 63 aged controls and 44 AD patients the effects of the MAOA-VNTR on MAOA gene expression and activity in the pineal gland as endophenotypes, and on melatonin production.

RESULTS

AD patients carrying long MAOA-VNTR genotype (consisting of 3.5- or 4-repeat alleles) showed higher MAOA gene expression and activity than the short-genotyped (i.e., 3-repeat allele) AD patients. Moreover, the AD-related up-regulation of MAOA showed up only among long-genotype bearing subjects. There was no significant effect of the MAOA-VNTR on MAOA activity or gene expression in controls, or on melatonin production in both controls and AD patients.

CONCLUSION

Our data suggest that the MAOA-VNTR affects the activity and gene expression of MAOA in the brain of AD patients, and is involved in the changes of monoamine metabolism.

Contribution of depression to cognitive impairment and dementia in older adults

BACKGROUND

The objective of this review is to provide information for clinicians regarding current research and opinions on the association of depression to conditions of cognitive impairment and dementia. We also intend to integrate this current research and thinking into strategies for the assessment and treatment of depression in the context of cognitive impairment.

REVIEW SUMMARY

Depression is highly prevalent in mild cognitive impairment and most dementias. It may be a risk factor for the subsequent development of dementia and in some conditions may be a prodromal symptom. It is important to detect and effectively treat depression because the comorbidity of depression and cognitive impairment is associated with greater cognitive and functional decline and higher rates of institutionalization. Depression often can be differentiated from Alzheimer disease and other dementias based on characteristics of clinical history and presentation. Screening of depression and cognitive impairment will help characterize the presence and severity of these conditions, but limitations in screening approaches may necessitate comprehensive assessment in complex cases where differential diagnosis is important to treatment planning.

CONCLUSION

Although depression and cognitive impairment are important issues in the treatment of older adults, there are particular risks when they occur together. Appropriate assessment and screening can help guide the clinician to appropriate and timely interventions. Pharmacologic and nonpharmacologic treatment approaches are both efficacious in reducing depression in cognitive impairment and dementia.

Assisted living policies promoting autonomy and their relationship to resident depressive symptoms

OBJECTIVE

The objective of this study is to determine the relationship between facility policies regarding autonomy and depression among residents of residential care/assisted living (RC/AL) facilities.

METHOD

A stratified sample of RC/AL facilities in Florida, Maryland, New Jersey, and North Carolina participated in the study. Patient characteristics for individuals 65 years and older were obtained from medical record reviews and in-person interviews. Facility administrators provided data on facility characteristics. Data on 1,098 residents were used to examine the relationship between facility policies as measured by domains of the Policy and Program Information Form and resident depressive symptoms and its factors as measured by the Cornell Scale for Depression in Dementia. Generalized estimating equation regression analysis was used to examine this relationship and control for other explanatory variables and clustering.

RESULTS

Among the policy variables examined, only the degree to which residents were involved in facility administration was consistently associated with depressive symptoms. Greater resident influence over facility policies and involvement in facility administration was significantly associated with lower levels of depressive symptoms. Resident control over their daily activities, the facility's tolerance for disruptive behavior, and the extent to which facilities had formal mechanisms for defining expected behavior were not significantly associated with levels of depressive symptoms.

CONCLUSIONS

Although some facilities provide residents with opportunities to select activities or meal times, these policies were not associated with depressive symptoms. However, results are consistent with the hypothesis that resident involvement in facility administrative decision-making is associated with fewer depressive symptoms. Future research should explore the causal nature of this relationship and might provide guidance for policy and practice.

Dental management of patients with stroke or Alzheimer's disease

Dentists are caring for an older population with significant comorbidities. It is necessary to be familiar with a patient's medical history and medications and how they may affect the care provided. This article focuses on patients with history of strokes or Alzheimer's disease.