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Menon NJ, Sun C, Chhina J, Halvorson BD, Frisbee JC, Frisbee SJ. Cerebrovascular dysfunction and depressive symptoms in preclinical models: insights from a scoping review. J Appl Physiol (1985) 2024; 136:1352-1363. [PMID: 38601994 DOI: 10.1152/japplphysiol.00031.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/11/2024] [Accepted: 04/05/2024] [Indexed: 04/12/2024] Open
Abstract
Although existing literature supports associations between cerebrovascular dysfunction and the emergence of depression and depressive symptoms, relatively little is known about underlying mechanistic pathways that may explain potential relationships. As such, an integrated understanding of these relationships in preclinical models could provide insight into the nature of the relationship, basic mechanistic linkages, and areas in which additional investment should be targeted. This scoping review was conducted in MEDLINE, EMBASE, and Scopus to outline the relationship between depressive symptoms and cerebrovascular dysfunction in preclinical animal models with an additional focus on the areas above. From 3,438 articles initially identified, 15 studies met the inclusion criteria and were included in the review. All studies reported a positive association between the severity of markers for cerebrovascular dysfunction and that for depressive symptoms in rodent models and this spanned all models for either pathology. Specific mechanistic links between the two such as chronic inflammation, elevated vascular oxidant stress, and altered serotonergic signaling were highlighted. Notably, almost all studies addressed outcomes in male animals, with a near complete lack of data from females, and there was little consistency in terms of how cerebrovascular dysfunction was assessed. Across nearly all studies was a lack of clarity for any "cause and effect" relationship between depressive symptoms and cerebrovascular dysfunction. At this time, it is reasonable to conclude that a correlative relationship clearly exists between the two, and future investigation will be required to parse out more specific aspects of this relationship.NEW & NOTEWORTHY This scoping review presents a structured evaluation of all relevant existing literature linking cerebral vasculopathy to depressive symptom emergence in preclinical models. Results support a definite connection between vascular dysfunction and depressive symptoms, highlighting the importance of chronic elevations in inflammation and oxidant stress, and impaired serotonergic signaling. The review also identified significant knowledge gaps addressing male versus female differences and limited clear mechanistic links between cerebral vasculopathy and depressive symptoms.
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Affiliation(s)
- Nithin J Menon
- Department of Medical Biophysics, University of Western Ontario, London, Ontario, Canada
| | - Clara Sun
- Department of Medical Biophysics, University of Western Ontario, London, Ontario, Canada
| | - Jashnoor Chhina
- Department of Medical Biophysics, University of Western Ontario, London, Ontario, Canada
| | - Brayden D Halvorson
- Department of Medical Biophysics, University of Western Ontario, London, Ontario, Canada
| | - Jefferson C Frisbee
- Department of Medical Biophysics, University of Western Ontario, London, Ontario, Canada
| | - Stephanie J Frisbee
- Department of Pathology and Laboratory Medicine, University of Western Ontario, London, Ontario, Canada
- Department of Epidemiology, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
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Yu OC, Jung B, Go H, Park M, Ha IH. Association between dementia and depression: a retrospective study using the Korean National Health Insurance Service-National Sample Cohort database. BMJ Open 2020; 10:e034924. [PMID: 33020075 PMCID: PMC7537455 DOI: 10.1136/bmjopen-2019-034924] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES Dementia is common in people over the age of 65 years, with 80% of people with dementia older than 75 years. Previous studies have linked dementia to late-life depression, but the association between dementia and mid-life depression is poorly understood. Depression is a preventable and treatable medical condition, which means it is a modifiable factor that can potentially prevent or delay dementia. This study aimed to identify the association between dementia and depression within the life course. DESIGN A nationwide, retrospective propensity score matched cohort study associating dementia with depression. Depression diagnosed between the ages of 45 and 64 years was classified as 'mid-life' and 'late-life' if diagnosed at 65 years or older. Patients were considered to have depression when one or more International Statistical Classification of Diseases and Related Health Problems, 10th revision codes for depression were recorded as primary or secondary diagnosis. SETTING National Health Insurance Service-National Sample Cohort database of the National Health Insurance Service in South Korea, containing patient data from 2002 to 2013. PARTICIPANTS The study included 1824 and 374 852 patients in the case and control groups, respectively. A logistic regression analysis with complex sampling design was performed after adjusting for covariates, using the propensity score matching method without callipers, with a 1:1 nearest neighbour matching algorithm. PRIMARY AND SECONDARY OUTCOME MEASURES The association of mid-onset and late-onset depression with dementia in terms of sociodemographic characteristics, such as sex and age, within the Korean population. RESULTS Dementia was significantly associated with the presence of depression (OR=2.20, 95% CI=1.53-3.14); in particular, female patients with depression and patients aged 45-64 years with depression had increased odds of dementia (OR=2.65, 95% CI=1.78-3.93 and OR=2.72, 95% CI=1.41-5.24, respectively) CONCLUSION: Depression is an associated factor for dementia, especially among people aged 45-64 years (mid-life).
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Affiliation(s)
- Ok-Cheol Yu
- Department of Korean rehabilitation medicine, Janseng Hospital of Korean Medicine, Seoul, Republic of Korea
| | - Boyoung Jung
- Department of Health Administration, Hanyang Women's University, Seoul, Republic of Korea
| | - Hoyeon Go
- Korean Internal Medicine, Semyung University, Korea, Chungju, Republic of Korea
- Herbal medicine policy division, Ministry of Food and Drug safety, Sejong-si, Republic of Korea
| | - Minjung Park
- National Agency for Development of Innovative Technologies in Korean Medicine, National Institute of Korean Medicine Development, Seoul, Republic of Korea
| | - In-Hyuk Ha
- Department of clinical research, Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
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Psychiatric symptoms and use of psychotropic medication in elderly fall and syncope patients. Eur Geriatr Med 2017. [DOI: 10.1016/j.eurger.2017.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Persson N, Ghisletta P, Dahle CL, Bender AR, Yang Y, Yuan P, Daugherty AM, Raz N. Regional brain shrinkage and change in cognitive performance over two years: The bidirectional influences of the brain and cognitive reserve factors. Neuroimage 2015; 126:15-26. [PMID: 26584866 DOI: 10.1016/j.neuroimage.2015.11.028] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 10/24/2015] [Accepted: 11/09/2015] [Indexed: 11/16/2022] Open
Abstract
We examined relationships between regional brain shrinkage and changes in cognitive performance, while taking into account the influence of chronological age, vascular risk, Apolipoprotein E variant and socioeconomic status. Regional brain volumes and cognitive performance were assessed in 167 healthy adults (age 19-79 at baseline), 90 of whom returned for the follow-up after two years. Brain volumes were measured in six regions of interest (ROIs): lateral prefrontal cortex (LPFC), prefrontal white matter (PFw), hippocampus (Hc), parahippocampal gyrus (PhG), cerebellar hemispheres (CbH), and primary visual cortex (VC), and cognitive performance was evaluated in three domains: episodic memory (EM), fluid intelligence (Gf), and vocabulary (V). Average volume loss was observed in Hc, PhG and CbH, but reliable individual differences were noted in all examined ROIs. Average positive change was observed in EM and V performance but not in Gf scores, yet only the last evidenced individual differences in change. We observed reciprocal influences among neuroanatomical and cognitive variables. Larger brain volumes at baseline predicted greater individual gains in Gf, but differences in LPFC volume change were in part explained by baseline level of cognitive performance. In one region (PFw), individual change in volume was coupled with change in Gf. Larger initial brain volumes did not predict slower shrinkage. The results underscore the complex role of brain maintenance and cognitive reserve in adult development.
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Affiliation(s)
- Ninni Persson
- Department of Psychology, Stockholm University, Sweden; Stockholm Brain Institute, Sweden
| | - Paolo Ghisletta
- Faculty of Psychology and Educational Sciences, University of Geneva, Switzerland; Distance Learning University, Sierre, Switzerland
| | - Cheryl L Dahle
- Institute of Gerontology, Wayne State University, Detroit, USA
| | - Andrew R Bender
- Institute of Gerontology, Wayne State University, Detroit, USA; Department of Psychology, Wayne State University, Detroit, USA
| | - Yiqin Yang
- Institute of Gerontology, Wayne State University, Detroit, USA
| | - Peng Yuan
- Institute of Gerontology, Wayne State University, Detroit, USA; Department of Psychology, Wayne State University, Detroit, USA
| | - Ana M Daugherty
- Institute of Gerontology, Wayne State University, Detroit, USA
| | - Naftali Raz
- Institute of Gerontology, Wayne State University, Detroit, USA; Department of Psychology, Wayne State University, Detroit, USA; Institute of Gerontology, Wayne State University, 87 East Ferry St., Detroit, MI 48201, USA.
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Abstract
Depression is very common throughout the course of veterans' lives, and dementia is common in late life. Previous studies suggest an association between depression and dementia in military veterans. The most likely biologic mechanisms that may link depression and dementia among military veterans include vascular disease, changes in glucocorticoid steroids and hippocampal atrophy, deposition of β-amyloid plaques, inflammatory changes, and alterations of nerve growth factors. In addition, military veterans often have depression comorbid with posttraumatic stress disorder or traumatic brain injury. Therefore, in military veterans, these hypothesized biologic pathways going from depression to dementia are more than likely influenced by trauma-related processes. Treatment strategies for depression, posttraumatic stress disorder, or traumatic brain injury could alter these pathways and as a result decrease the risk for dementia. Given the projected increase of dementia, as well as the projected increase in the older segment of the veteran population, in the future, it is critically important that we understand whether treatment for depression alone or combined with other regimens improves cognition. In this review, we summarize the principal mechanisms of this relationship and discuss treatment implications in military veterans.
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Ibrahim N, Din NC, Ahmad M, Ghazali SE, Said Z, Shahar S, Ghazali AR, Razali R. Relationships between social support and depression, and quality of life of the elderly in a rural community in Malaysia. Asia Pac Psychiatry 2013; 5 Suppl 1:59-66. [PMID: 23857839 DOI: 10.1111/appy.12068] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION This study aimed to examine the role of social support and depression in predicting the quality of life among the elderly living in a rural Federal Land Development Authority (FELDA) community in Malaysia. METHODS A total of 162 elderly settlers of FELDA Sungai Tengi, aged 60 years and above, were selected by universal sampling method in this cross-sectional study. Three standardized instruments - the 12-item Short Form (SF-12), 15-item Geriatric Depression Scale (GDS-15) and Medical Outcome Study Social Support (MOS-Social Support) - were used to assess for quality of life, depression and social support. RESULTS Quality of life of the elderly people in this community was high, especially in terms of physical components as compared to mental components. The mean scores for emotional role in the SF-12 was relatively the highest (90.74 ± 21.59) with social functioning being the lowest (30.35 ± 22.29). The results also showed that the mean value was higher for physical component summary (74.40) as compared to mental component summary (51.51). Approximately 23.5% suffered mild depression and only 2.5% had severe depression. DISCUSSION This study showed that the elderly FELDA settlers have a high quality of life, mainly on the physical components of life and low rate of severe depression, a positive indicator of their psychological well-being. Social support in the form of emotional/informational support, and depression were significant factors related to their good quality of life.
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Affiliation(s)
- Norhayati Ibrahim
- Health Psychology Program, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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Murphy JA, Byrne GJ. Prevalence and correlates of the proposed DSM-5 diagnosis of Chronic Depressive Disorder. J Affect Disord 2012; 139:172-80. [PMID: 22381955 DOI: 10.1016/j.jad.2012.01.033] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Revised: 01/30/2012] [Accepted: 01/30/2012] [Indexed: 10/28/2022]
Abstract
CONTEXT The draft proposal to add Chronic Depressive Disorder to DSM-5 will combine DSM-IV Dysthymic Disorder and Major Depressive Disorder, with chronic specifier, into a single diagnosis. OBJECTIVE The objective of this study is to estimate the prevalence and correlates of the proposed DSM-5 diagnosis of Chronic Depressive Disorder using unit record data from the 2007 Australian National Survey of Mental Health and Wellbeing. DESIGN Secondary analysis of a nationally representative household survey. SETTING Urban and rural census tracts. PARTICIPANTS One individual between the ages of 16 and 85 years from 8841 households was interviewed for the survey. MAIN OUTCOME MEASURE Lifetime prevalence estimates for chronic and non-chronic depression were determined using data from the World Health Organization's Composite International Diagnostic Interview, version 3.0 (WMH-CIDI 3.0). RESULTS Chronic depression of at least two years' duration had a lifetime prevalence of 4.6% (95% CI: 3.9-5.3%) and was found in 29.4% (95% CI: 25.6-33.3%) of individuals with a lifetime depressive disorder. Higher rates of psychiatric co-morbidity (OR=1.42; 95% CI=1.26-1.61), older age (OR=1.04; 95% CI=1.02-1.05), a younger age of onset (OR=0.97; 95% CI=0.95-0.98) and more frequent episodes of depression (OR=1.75; 95% CI=1.07-2.86) were found to be significant correlates of chronic depression. The first episode of depression for individuals with chronic depression often developed after the death of someone close (OR=2.38; 95% CI 1.16-5.79). CONCLUSIONS Chronic depression is highly prevalent among community-residing persons and has a set of correlates that discriminate it from non-chronic depression. The distinction between chronic and non-chronic depression proposed for DSM-5, in the form of Chronic Depressive Disorder, seems to be warranted.
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Affiliation(s)
- Jenifer A Murphy
- The University of Queensland, School of Medicine, Academic Discipline of Psychiatry, K Floor, Mental Health Centre, Royal Brisbane and Women's Hospital, Herston, QLD 4029, Australia.
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Luijendijk HJ, Stricker BHC, Wieberdink RG, Koudstaal PJ, Hofman A, Breteler MM, Tiemeier H. Transient ischemic attack and incident depression. Stroke 2011; 42:1857-61. [PMID: 21566240 DOI: 10.1161/strokeaha.110.604405] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Depression after stroke is common. Like stroke, transient ischemic attack (TIA) is a manifestation of long-term atherosclerotic damage to the brain. However, the risk of depression developing after a TIA is uncertain. We studied whether TIA increases the risk of incident late-life depression. METHODS A cohort study of 5095 inhabitants of Rotterdam, the Netherlands, was performed between 1993 and 2005. Participants were aged 56 years or older and free of depression at baseline. TIA and depression were identified through regular standardized examinations and continuous monitoring of medical records. We estimated hazard ratios (HR) with time-varying Cox regression analyses, adjusting for sociodemographic and health-related factors. RESULTS During follow-up, 407 depressive syndromes occurred, of which 103 met criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM) for depressive disorders. TIA was significantly associated with the risk of incident depressive syndromes (HR, 1.68; 95% CI, 1.12-2.51) and DSM-defined depressive disorders (HR, 2.42; 95% CI, 1.26-4.67). The risk of depressive syndromes increased with the number of TIA a person had experienced (HR, 1.45; 95% CI, 1.17-1.81), as did the risk of depressive disorders (HR, 1.63; 95% CI, 1.18-2.24). In persons without a history of depression at baseline, we found an almost 3-fold increased risk of DSM-defined depressive disorders (HR, 2.91; 95% CI, 0.96-8.81). CONCLUSIONS TIA was independently associated with an increased risk of incident depression. Our finding suggests that symptomatic cerebrovascular disease increases the vulnerability to late-life depression.
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Affiliation(s)
- Hendrika J Luijendijk
- Erasmus Medical Center, Department of Epidemiology, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
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Abstract
Depression is highly common throughout the life course and dementia is common in late life. Depression has been linked with dementia, and growing evidence implies that the timing of depression may be important in defining the nature of this association. In particular, earlier-life depression (or depressive symptoms) has consistently been associated with a more than twofold increase in dementia risk. By contrast, studies of late-life depression and dementia risk have been conflicting; most support an association, yet the nature of this association (for example, if depression is a prodrome or consequence of, or risk factor for dementia) remains unclear. The likely biological mechanisms linking depression to dementia include vascular disease, alterations in glucocorticoid steroid levels and hippocampal atrophy, increased deposition of amyloid-β plaques, inflammatory changes, and deficits of nerve growth factors. Treatment strategies for depression could interfere with these pathways and alter the risk of dementia. Given the projected increase in dementia incidence in the coming decades, understanding whether treatment for depression alone, or combined with other regimens, improves cognition is of critical importance. In this Review, we summarize and analyze current evidence linking late-life and earlier-life depression and dementia, and discuss the primary underlying mechanisms and implications for treatment.
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Rondanelli M, Giacosa A, Opizzi A, Pelucchi C, La Vecchia C, Montorfano G, Negroni M, Berra B, Politi P, Rizzo AM. Effect of omega-3 fatty acids supplementation on depressive symptoms and on health-related quality of life in the treatment of elderly women with depression: a double-blind, placebo-controlled, randomized clinical trial. J Am Coll Nutr 2010; 29:55-64. [PMID: 20595646 DOI: 10.1080/07315724.2010.10719817] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE In elderly individuals, depression is one of the most frequently missed diagnoses with negative effects on quality of life. The authors investigated whether a supplement containing long-chain omega-3 polyunsaturated fatty acids (n-3 LCPUFA) improves depressive symptoms and health-related quality of life (HRQoL) in depressed elderly patients. DESIGN Eight-week, randomized, double-blind, placebo-controlled trial. SETTING Nursing home in Pavia, Italy. PARTICIPANTS Forty-six depressed women, aged 66-95 years. INTERVENTION Twenty-two depressed women were included in the intervention group (n-3 group, which received 2.5 g/d of n-3 LCPUFA, with 1.67 g of eicosapentaenoic acid [EPA] and 0.83 g of docosahesaenoic acid [DHA]), and 24 patients were included in the placebo group. The primary endpoint was the improvement of depressive symptoms, as evaluated by the Geriatric Depression Scale (GDS). Secondary endpoints were the evaluation of HRQoL, by using the Short-Form 36-Item Health Survey (SF-36), and modifications of erythrocyte membrane phospholipids fatty acid profile. All variables were assessed before and after the treatment period of 8 weeks. RESULTS The mean GDS at 8 weeks was significantly lower compared with the n-3 group. The SF-36 physical and mental components were significantly increased in the intervention group. Compliance was good, as confirmed by erythrocyte membrane phospholipid FA concentrations, with a significant increase of EPA and DHA in the intervention group. CONCLUSION Supplementation with n-3 LCPUFA is efficacious in the amelioration of depressive symptoms and quality of life in the treatment of depressed elderly female patients.
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Affiliation(s)
- Mariangela Rondanelli
- Department of Applied Health Sciences, Section of Human Nutrition and Dietetics, Faculty of Medicine, University of Pavia, Pavia, Italy. or
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Abstract
Poststroke depression (PSD) in elderly patients has been considered the most common neuropsychiatric consequence of stroke up to 6-24 months after stroke onset. When depression appears within days after stroke onset, it is likely to remit, whereas depression at 3 months is likely to be sustained for 1 year. One of the major problems posed by elderly stroke patients is how to identify and optimally manage PSD. This review provides insight to identification and management of depression in elderly stroke patients. Depression following stroke is less likely to include dysphoria and more likely characterized by vegetative signs and symptoms compared with other forms of late-life depression, and clinicians should rely more on nonsomatic symptoms rather than somatic symptoms. Evaluation and diagnosis of depression among elderly stroke patients are more complex due to vague symptoms of depression, overlapping signs and symptoms of stroke and depression, lack of properly trained health care personnel, and insufficient assessment tools for proper diagnosis. Major goals of treatment are to reduce depressive symptoms, improve mood and quality of life, and reduce the risk of medical complications including relapse. Antidepressants (ADs) are generally not indicated in mild forms because the balance of benefit and risk is not satisfactory in elderly stroke patients. Selective serotonin reuptake inhibitors are the first choice of PSD treatment in elderly patients due to their lower potential for drug interaction and side effects, which are more common with tricyclic ADs. Recently, stimulant medications have emerged as promising new therapeutic interventions for PSD and are now the subject of rigorous clinical trials. Cognitive behavioral therapy can also be useful, and electroconvulsive therapy is available for patients with severe refractory PSD.
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Affiliation(s)
- Johan Lökk
- Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden.
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Blanchette CM, Simoni-Wastila L, Shaya FT, Orwig D, Noel J, Stuart B. Depression following thrombotic cardiovascular events in elderly medicare beneficiaries: risk of morbidity and mortality. Cardiol Res Pract 2010; 2009:194528. [PMID: 20069046 PMCID: PMC2800999 DOI: 10.4061/2009/194528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2009] [Revised: 08/07/2009] [Accepted: 09/24/2009] [Indexed: 11/20/2022] Open
Abstract
Purpose. Depression and antidepressant use may independently increase the risk of acute myocardial infarction and mortality in adults. However, no studies have looked at the effect of depression on a broader thrombotic event outcome, assessed antidepressant use, or evaluated elderly adults. Methods. A cohort of 7,051 community-dwelling elderly beneficiaries who experienced a thrombotic cardiovascular event (TCE) were pooled from the 1997 to 2002 Medicare Current Beneficiary Survey and followed for 12 months. Baseline characteristics, antidepressant utilization, and death were ascertained from the survey, while indexed TCE, recurrent TCE, and depression (within 6 months of indexed TCE) were taken from ICD-9 codes on Medicare claims. Time to death and first recurrent TCE were assessed using descriptive and multivariate statistics. Results. Of the elders with a depression claim, 71.6% had a recurrent TCE and 4.7% died within 12 months of their indexed TCE, compared to 67.6% and 3.9% of those elders without a depression claim. Of the antidepressant users, 72.6% experienced a recurrent TCE and 3.9% died, compared to 73.7% and 4.6% in the subset of selective serotonin reuptake inhibitor (SSRI) users. Depression was associated with a shorter time to death (P = .008) in the unadjusted analysis. However, all adjusted comparisons revealed no effect by depression, antidepressant use, or SSRI use. Conclusions. Depression was not associated with time to death or recurrent TCEs in this study. Antidepressant use, including measures of any antidepressant use and SSRI use, was not associated with shorter time to death or recurrent TCE.
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Affiliation(s)
- Christopher M Blanchette
- Division of Clinical and Outcomes Research, Lovelace Respiratory Research Institute, Albuquerque, NM 87108, USA
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Blanchette CM, Simoni-Wastila L, Shaya F, Orwig D, Noel J, Stuart B. Health care use in depressed, elderly, cardiac patients and the effect of antidepressant use. Am J Health Syst Pharm 2009; 66:366-72. [DOI: 10.2146/ajhp080092] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Christopher M. Blanchette
- Center for Pharmacoeconomics and Outcomes Research, Lovelace Respiratory Research Institute, Kannapolis, NC, and Adjunct Assistant Professor, Division of Pharmaceutical Outcomes and Policy, School of Pharmacy, University of North Carolina, Chapel Hill
| | | | - Fadia Shaya
- Department of Pharmaceutical Health Services Research, University of Maryland Baltimore School of Pharmacy, Baltimore
| | - Denise Orwig
- Department of Epidemiology and Preventive Medicine, School of Medicine
| | - Jason Noel
- University of Maryland Baltimore School of Pharmacy
| | - Bruce Stuart
- Peter Lamy Center on Drug Therapy and Aging, Department of Pharmaceutical Health Services Research, University of Maryland Baltimore School of Pharmacy
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Panza F, D'Introno A, Colacicco AM, Capurso C, Del Parigi A, Caselli RJ, Todarello O, Pellicani V, Santamato A, Scapicchio P, Maggi S, Scafato E, Gandin C, Capurso A, Solfrizzi V. Depressive symptoms, vascular risk factors and mild cognitive impairment. The Italian longitudinal study on aging. Dement Geriatr Cogn Disord 2008; 25:336-46. [PMID: 18319599 DOI: 10.1159/000119522] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2007] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Francesco Panza
- Department of Geriatrics, Center for Aging Brain, Memory Unit, University of Bari, Bari, Italy.
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Godin O, Dufouil C, Maillard P, Delcroix N, Mazoyer B, Crivello F, Alpérovitch A, Tzourio C. White matter lesions as a predictor of depression in the elderly: the 3C-Dijon study. Biol Psychiatry 2008; 63:663-9. [PMID: 17977521 DOI: 10.1016/j.biopsych.2007.09.006] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2007] [Revised: 08/31/2007] [Accepted: 09/12/2007] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is increasing evidence for a link between cerebrovascular disease and depression in the elderly but the mechanisms are still unknown. This study examines the longitudinal relationship between depression and white matter lesions (WML) in a sample of elderly aged 65 years and older. METHODS Three City (3C)-Dijon is a 4-year follow-up population-based prospective study of 1658 subjects. At baseline, lifetime major depressive episode diagnosis was established using the Mini International Neuropsychiatric Interview. At each study wave, severity of depressive symptoms was assessed using Center for Epidemiological Studies-Depression (CES-D), and antidepressants intake was recorded. At baseline, lifetime major depression (LMD) was defined as lifetime major depressive episode or antidepressant medication intake. At follow-up, subjects were classified "incident depression" if scoring high at CES-D or antidepressant users. At baseline, cerebral magnetic resonance imaging (MRI) was performed to quantify WML volumes using an automated method of detection. At 4-year follow-up, 1214 subjects had a second MRI. RESULTS Cross-sectional analysis showed a significantly higher WML volume in subjects with LMD compared with other subjects. Adjusted longitudinal analysis showed that increase in WML load was significantly higher in subjects with baseline LMD (2.1 cm(3) vs. 1.5 cm(3), p = .004). Among subjects free of depression up to baseline (n = 956), the higher the baseline WML volume, the higher the risk of developing depression during follow-up (odds ratio one quartile increase: 1.3; 95% confidence interval: = 1.1-1.7). CONCLUSIONS Our data show that depression and WML volumes are strongly related. These results are consistent with the hypothesis of a vascular depression in the elderly.
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Affiliation(s)
- Ophélia Godin
- Neuroepidemiology, Institut National de Santé et de Recherche Médicale, Paris, France.
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Lindén T, Blomstrand C, Skoog I. Depressive disorders after 20 months in elderly stroke patients: a case-control study. Stroke 2007; 38:1860-3. [PMID: 17431211 DOI: 10.1161/strokeaha.106.471805] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Depression is common after stroke. Reported frequencies vary widely between studies because of differences in patient selection, time from stroke to assessment, evaluation methods and diagnostic criteria. Poststroke depression is related to increased mortality and poorer rehabilitation outcome. Few studies have been done in the elderly, and there is a lack of studies with population-based controls. We aimed to examine the risk of depression in elderly patients one and a half years after stroke and to compare the risk with a population-based control sample. METHODS We examined 149 elderly stroke survivors and 745 age- and sex-matched controls from the general population with semistructured psychiatric examinations and cognitive assessments. Diagnoses were made according to DSM-III-R. Independent samples t test and chi(2) test were used to test for significance, Mantel-Haenszel odds ratios with 95% CI for relative risk and Tarone statistics for risk differences between groups. RESULTS The frequency of depression was 34% in stroke patients and 13% in population controls (odds ratio, 3.4; 95% CI, 2.3 to 5.0). The risk of depression was increased in both men and women and in all age groups but not related to the predominant side of stroke symptoms. CONCLUSIONS Depression is common after stroke. It is therefore important to identify depression in stroke patients because it is a treatable condition that may have implications for poorer outcome in relation to rehabilitation and mortality.
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Affiliation(s)
- Thomas Lindén
- The Institute of Neuroscience and Physiology, Sahlgrenska Academy at Göteborg University, Sahlgrenska University Hospital, Göteborg, Sweden.
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18
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Abstract
Psychiatric disorders such as depression are common conditions in older adults. Depression presents similarly to younger adults, but with more psychotic symptoms and apathy. Research has suggested that genetics play a less important role in the etiology of depression in the elderly, but that other biological factors may be more significant. Vascular pathology in particular is thought to be especially important. White-matter hyperintensities are found in the frontal lobes and basal ganglia in greater numbers in older adults with depression, with damage to the frontal–subcortical circuits thought to be particularly important. It is associated with treatment resistance. Prognosis is poor if depression is not detected and treated adequately and this may lead to a higher risk of dementia and death. However, treatment with selective serotonin reuptake inhibitors and other antidepressants, plus psychological therapies, are effective in the older depressed patient and reduce morbidity and mortality.
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Affiliation(s)
- Emma Teper
- Wolfson Research Centre, Institute for Ageing and Health, Newcastle General Hospital, Newcastle upon Tyne, NE4 6BE, UK
| | - Alan Thomas
- Wolfson Research Centre, Institute for Ageing and Health, Newcastle General Hospital, Newcastle upon Tyne, NE4 6BE, UK
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Glamcevski MT, Pierson J. Prevalence of and Factors Associated with Poststroke Depression: A Malaysian Study. J Stroke Cerebrovasc Dis 2005; 14:157-61. [PMID: 17904018 DOI: 10.1016/j.jstrokecerebrovasdis.2005.03.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2005] [Accepted: 03/16/2005] [Indexed: 01/09/2023] Open
Abstract
This study investigated the prevalence of depression 3-6 months poststroke and examined specific factors associated with depression in a stroke population of the University Malaya Medical Centre, Kuala Lumpur, Malaysia. It was hypothesised that poststroke depression (PSD) is prevalent in the poststroke population of University Hospital Malaysia and that PSD is significantly correlated with demographics, educational background, medical history, rehabilitation attendance, traditional medicine use, prestroke and poststroke activities, religiousness, activities of daily living, and social support. The study group comprised 80 patients admitted to the hospital with stroke of any etiology. Mean patient age was 56.8 years (standard deviation +/- 12.5 years). The results were derived by comparing the 80 stroke patients with 80 controls matched for age, sex, race, and medication use. Results were also derived from comparisons between depressed and nondepressed members of the stroke population (n = 80). The diagnosis of depression was based on the Zung Self-Rating Scale and confirmed by a psychiatrist, based on DSM-IV criteria. Interviews were conducted based on a 26-item questionnaire, modified Barthel Index, and Social Resources Scale were used to assess which factors correlated with depression. Depression was found to be common among Malaysians 3-6 months after stroke. A total of 66% of the patients were depressed, with depression considered mild in 51% and moderate to severe in 15%. It was demonstrated that the occurrence of depression was significantly correlated with age, ethnicity, noncontinuance of prestroke lifestyles, and poor performance in the activities of daily living rating.
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Affiliation(s)
- Mihajlo Tome Glamcevski
- Counselling Department, School of Public Health, La Trobe University, Bundoora, Victoria, Australia; Center for Psychology, HELP Institute, Kuala Lumpur, Malaysia
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Tang WK, Chan SSM, Chiu HFK, Ungvari GS, Wong KS, Kwok TCY, Mok V, Wong KT, Richards PS, Ahuja AT. Poststroke depression in Chinese patients: frequency, psychosocial, clinical, and radiological determinants. J Geriatr Psychiatry Neurol 2005; 18:45-51. [PMID: 15681628 DOI: 10.1177/0891988704271764] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study attempted to evaluate the psychosocial, clinical, and radiological predictors of poststroke depression (PSD) in Chinese patients. One hundred eighty-nine patients participated in the study. Three months after the index stroke, a psychiatrist administered the Structured Clinical Interview for DSM-IV to all of the patients and made a DSM-IV diagnosis of depression. In addition, a host of demographic, clinical, and radiological variables were examined. Thirty-one (16.4%) of the patients had a diagnosis of PSD that included major depression (n=11, 5.8%,), minor depression (n=16, 8.5%), or dysthymia (n=4, 2.1%). Univariate analysis revealed that PSD was associated with female gender, a lower level of education, a lower Lubben Social Network Scale (LSNS) score, subcortical infarcts, and lesions in the anterior cerebral artery (ACA) territory, and the Modified Life Event Scale (MLES) score was borderline for statistical significance. Multivariate logistic regression analysis suggested that female gender, a high MLES score, and subcortical and ACA lesions were independent risk factors for PSD and that a high LSNS score was a protective factor.
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Affiliation(s)
- Wai Kwong Tang
- Department of Psychiatry, Chinese University of Hong Kong, Hong Kong, SAR, China.
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21
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Bourgeois JA, Hilty DM, Chang CH, Wineinger MA, Servis ME. Poststroke Neuropsychiatric Illness: An Integrated Approach to Diagnosis and Management. Curr Treat Options Neurol 2004; 6:403-420. [PMID: 15279761 DOI: 10.1007/s11940-996-0031-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Patients who have had stroke are at significant risk for various neuropsychiatric illnesses. The most common and important of these are poststroke depression and poststroke dementia (attributable to vascular dementia, Alzheimer's dementia, or a combination of mechanisms). Poststroke neuropathology may lead some patients to experience concurrent and "overlapping" mood and cognitive symptoms. Less frequently, poststroke anxiety disorders, psychosis, isolated pathologic expressions of emotions, and apathy or fatigue may be encountered. The authors review the current literature on poststroke neuropsychiatry and offer an integrated approach to pathophysiologic concepts and clinical surveillance, screening, diagnosis, and evidence-based pharmacologic and nonpharmacologic intervention for these clinical problems on the clinical boundary between neurology and psychiatry.
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Affiliation(s)
- James A. Bourgeois
- Department of Psychiatry and Behavioral Sciences Rehabilitation, University of California, Davis Medical Center, 2230 Stockton Boulevard, Sacramento, CA 95817, USA. james.bour
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22
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Abstract
Background—
It has been hypothesized that poststroke depression (PSD) results from left hemisphere lesions. However, attempts to systematically review the data investigating lesion location and PSD have yielded conflicting results. We sought to investigate the methodological differences across the literature studying the relationship between lesion location and PSD.
Summary of Review—
A MEDLINE literature search to retrieve articles investigating the association between PSD and lesion location was performed. Information sought included source population of samples, definition of depression, standardized measurement of stroke and depression, blinding, time since stroke onset, and study design. Odds ratios (ORs) and 95% CIs were calculated with the use of Review Manager and MetaView statistical software. Twenty-six original articles were reviewed. Much of the heterogeneity across studies reflected differences in methodology. The direction of association between left hemisphere lesion location and PSD varied depending on whether patients were sampled as inpatients (OR, 1.36; 95% CI, 1.05 to 1.76) or from the community (OR, 0.60; 95% CI, 0.39 to 0.92). Change in the direction of association was also observed across assessment interval from the acute stroke (OR, 2.14; 95% CI, 1.50 to 3.04) to the chronic stroke (OR, 0.53; 95% CI, 0.30 to 0.93) phase. Differences in the measurement of depression, study design, and presentations of results also may have contributed to the heterogeneity of the findings.
Conclusions—
Several key initiatives should be addressed before future research is undertaken, including the development of a comprehensive measure of PSD, optimal poststroke assessment intervals, and determination of a representative population reference.
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Affiliation(s)
- Sanjit K Bhogal
- Department of Physical Medicine and Rehabilitation, St. Joseph's Health Care London, London, Ontario, Canada.
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23
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Watkins LL, Schneiderman N, Blumenthal JA, Sheps DS, Catellier D, Taylor CB, Freedland KE. Cognitive and somatic symptoms of depression are associated with medical comorbidity in patients after acute myocardial infarction. Am Heart J 2003; 146:48-54. [PMID: 12851607 DOI: 10.1016/s0002-8703(03)00083-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Depression is common in patients with acute myocardial infarction (AMI) and is associated with adverse health outcomes. However, the extent to which clinical depression is related to comorbid medical conditions is unknown. This study examined the degree of association between clinical depression and medical comorbidity in patients hospitalized with AMI. METHODS Two thousand four hundred and eighty-one depressed or socially isolated patients with AMI were enrolled, as part of the National Heart, Lung, and Blood Institute-sponsored Enhancing Recovery in Coronary Heart Disease clinical trial. A structured interview was used to diagnose major and minor depression and dysthymia; severity of depression was measured by the Hamilton Rating Scale for Depression and the Beck Depression Inventory. Level of social support was measured by the ENRICHD Social Support Instrument. A modified version of the Charlson Comorbidity Index was used to measure the cumulative burden of medical comorbidity. RESULTS The adjusted odds ratios (ORs) for having major depression increased linearly with medical comorbidity (ORs 1.6, 2.2, 2.7 for each increasing medical comorbidity category). This relationship remained after adjusting for coronary heart disease severity (ORs 1.4, 1.7, 1.9, P <.001). The relationship between severity of depression and medical comorbidity was also maintained after excluding somatic symptoms of depression (F = 21.5, P <.0001). CONCLUSIONS Patients with AMI and clinical depression have significantly greater levels of medical comorbidity than nondepressed, socially isolated patients. Further research is needed to determine whether comorbid medical illness contributes to the more frequent rehospitalizations and increased risk of mortality associated with depression.
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Affiliation(s)
- Lana L Watkins
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA.
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Perez J, Tardito D. The interface between depression and cerebrovascular disease--some hope but no hype. Clin Exp Hypertens 2002; 24:639-46. [PMID: 12450239 DOI: 10.1081/ceh-120015340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Medical complications after stroke are an important problem not only for patients, but also for their families and the clinicians who take care of them, thus representing a major public health problem. Among medical illnessess complicating stroke, in the last several years much efforts has been directed to determine the role of affective disorders. Although depression coexisting with stroke has been shown to increase levels of functional disability and reduce the effectiveness of rehabilitation, we still have much to learn about the clinical interface between such disorders. This review focuses on the data concerning the potential relationship between depression and cerebrovascular disease (CVD) and the emerging insights which may be relevant to provide directions for the development of novel research strategies on the pathogenesis and treatment of post-stroke depression.
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Affiliation(s)
- Jorge Perez
- Istituto Scientifico H. San Raffaele, Department of Neuropsychiatry, School of Medicine, Università Vita-Salute, Via Stamira d'Ancona, Milan, Italy.
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Abstract
There are nearly 30 million women with disabilities in the United States. Of these, more than 16 million are over the age of 50. Years ago, women with disabilities did not commonly live to the age of menopause, and, if they did, they reached this stage of life in a very debilitated condition. Now, women with disabilities are entering their mature years as active members of society who can look forward to productive futures. Because the health needs of women with disabilities might differ from those of other women, special attention should be focused on how physiological changes of perimenopausal and menopausal states affect this population. In addition to functional changes that might affect menopausal women with disabilities, basic health maintenance issues may be adversely affected by environmental factors. Physical barriers can influence compliance with preventive health screening that is essential in aging populations. Treatment options might need to be tailored to the individual. The disabling condition itself may progress, resulting in secondary conditions requiring creative interventions. A comprehensive evaluation and the development of a suitable management plan, which takes into account the multifactorial nature of aging as a disabled woman, are essential in delivering optimal care to this population.
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Marmorato PG, Moreno RA, Keila SB, Moreno DH. Depression and dementia of cerebrovascular origin. REVISTA DO HOSPITAL DAS CLINICAS 2002; 57:25-30. [PMID: 12170346 DOI: 10.1590/s0041-87812002000100005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
We report the case of a patient who presented various psychiatric syndromes at the time of evaluation - partial complex epileptic seizures, personality change, and severe depression, which eventually progressed to dementia - resulting from multiple cerebral infarctions of probable neuro-angiopathic origin, of unknown etiology. Aspects related to depression following cerebrovascular accidents, as well as how cerebrovascular accidents can result in different disorders depending on the variables, are discussed based on the data from current literature.
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Wallin A, Sjögren M. Cerebrospinal fluid cytoskeleton proteins in patients with subcortical white-matter dementia. Mech Ageing Dev 2001; 122:1937-49. [PMID: 11589912 DOI: 10.1016/s0047-6374(01)00306-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The cerebrospinal fluid (CSF) levels of two cytoskeleton proteins, tau and the light subunit of neurofilament protein (NFL), both considered to reflect cerebral white-matter components, were investigated in a group of patients with a subtype of vascular dementia called 'subcortical white-matter dementia' (SWD). The group consisted of 25 demented patients with frontosubcortical brain syndromes, white-matter changes on computed tomography or magnetic resonance imaging and vascular disease or pronounced vascular risk factors. CSF-NFL was increased, whereas CSF-tau was normal, suggesting a differential involvement of the cytoskeleton in this patient group. The albumin ratio and the apolipoproteinE4 (ApoE4) allele status were also investigated. The albumin ratio was increased, indicating damage to the vessel walls with breakdown of the blood-brain barrier. No relationship was found between ApoE4 alleles and CSF levels of tau or NFL in this patient group. Besides presenting original data, the disease status of SWD is also discussed.
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Affiliation(s)
- A Wallin
- Institute of Clinical Neuroscience, Göteborg University, Sahlgrenska University Hospital, SE 431 80, Mölndal, Sweden.
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28
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Abstract
Those caring for stroke victims should be aware of new developments in our understanding of depression following stroke, its diagnosis, prevalence, pathophysiology, clinical features, and treatment. Appropriate diagnosis and treatment will improve quality of life, self-care independence, and mortality.
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Affiliation(s)
- D W Gawronski
- Burke Rehabilitation Hospital, Weill Medical College of Cornell University, 785 Mamaroneck Avenue, White Plains, NY 10605, USA.
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29
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Rogers PJ. A healthy body, a healthy mind: long-term impact of diet on mood and cognitive function. Proc Nutr Soc 2001; 60:135-43. [PMID: 11310419 DOI: 10.1079/pns200061] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Certain dietary risk factors for physical ill health are also risk factors for depression and cognitive impairment. Although cholesterol lowering has been suggested to increase vulnerability to depression, there is better support for an alternative hypothesis that intake of n-3 long-chain polyunsaturated fatty acids can affect mood (and aggression). Possible mechanisms for such effects include modification of neuronal cell membrane fluidity and consequent impact on neurotransmitter function. Stronger evidence exists concerning a role for diet in influencing cognitive impairment and cognitive decline in older age, in particular through its impact on vascular disease. For example, cognitive impairment is associated with atherosclerosis, type 2 diabetes and hypertension, and findings from a broad range of studies show significant relationships between cognitive function and intakes of various nutrients, including long-chain polyunsaturated fatty acids, antioxidant vitamins, and folate and vitamin B12. Further support is provided by data on nutrient status and cognitive function. Almost all this evidence, however, comes from epidemiological and correlational studies. Given the problem of separating cause and effect from such evidence, and the fact that cognitive impairment and cognitive decline (and depression) are very likely to be significant factors contributing to the consumption of a poor diet, greater emphasis should now be placed on conducting intervention studies. An efficient approach to this problem could be to include assessments of mood and cognitive function as outcome measures in studies designed primarily to investigate the impact of dietary interventions on markers of physical health.
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Affiliation(s)
- P J Rogers
- Department of Experimental Psychology, University of Bristol, UK.
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