Depressive symptoms increase the risk of progression to dementia in subjects with mild cognitive impairment: systematic review and meta-analysis

Cross-sectional and longitudinal associations between late-life depressive symptoms and cognitive deficits: 20-year follow-up of the Kuakini Honolulu-Asia aging study

OBJECTIVE

To examine depressed affect, somatic complaints, and positive affect as longitudinal predictors of fluid, crystallized and global cognitive performance in the Kuakini Honolulu-Asia Aging Study (HAAS), a large prospective cohort study of Japanese-American men.

METHODS

We assessed 3,088 dementia-free Kuakini-HAAS participants aged 71-93 (77.1 ± 4.2) years at baseline (1991-1993). Depressive symptoms were evaluated by the Center for Epidemiologic Studies Depression (CES-D) Scale. Baseline CES-D depression subscales (depressed and positive affects; somatic complaints) were computed. The Cognitive Abilities Screening Instrument (CASI) measured cognitive performance on a 100-point scale; fluid and crystallized cognitive abilities were derived from CASI factor analysis. Cognition was also evaluated at 4 follow-up examinations over a 20-year period. Multiple regression assessed baseline CES-D subscales as predictors of cognitive change. The baseline covariates analyzed were CASI, age, education, prevalent stroke, APOE ε4 presence, and the longevity-associated FOXO3 genotype.

RESULTS

Cross-sectionally, baseline CES-D subscales were related to cognitive measures; e.g., higher depressed affect was associated with lower crystallized ability (β = -0.058, p ≤ 0.01), and somatic complaints were linked to poorer fluid ability (β = -0.045, p ≤ 0.05) and to worse global cognitive function as measured by total CASI score (β = -0.038, p ≤ 0.05). However, depression subscales did not significantly or consistently predict fluid ability, crystallized ability, or global cognitive performance over time.

CONCLUSION

Psychological and physical well-being were associated with contemporaneous but not subsequent cognitive functioning. Assessment of depressive symptoms may identify individuals who are likely to benefit from interventions to improve mood and somatic health and thereby maintain or enhance cognition.

Sex-specific in the association between depressive symptoms and risk of cognitive impairment in Chinese older adults

BACKGROUND

Many studies have focused on the relationship between depressive symptoms and cognitive impairment, but gender differences in this relationship are unclear, especially among Chinese older adults. Therefore, this study explores whether there are gender differences between depressive symptoms and risk of cognitive impairment based on a survey of a Chinese older adult population.

STUDY DESIGN

This is a cross-sectional study.

METHOD

We screened 9678 older adults aged 65 to 105 from the 2018 CLHLS database. The 10-item Center for Epidemiological Studies Depression Scale (CESD-10) and Mini-Mental State Examination (MMSE) were utilized for measuring depressive symptoms and cognitive performance, respectively. Logistic regressions and restricted cubic spline were applied to investigate the relationship between depressive symptoms and cognitive impairment.

RESULTS

Of the 9678 participants, 4719 (48.8 %) were men. The association between severe depressive symptoms and cognitive impairment was more pronounced in older men (male × severe depressive symptoms: OR = 2.71, 95%CI = 1.07-6.92, p = 0.037). Compared with no depressive symptoms, severe depressive symptoms were associated with an almost five times greater risk of cognitive impairment in men (OR = 4.84, 95 % CI = 2.26-10.40, p < 0.001, compared to OR = 2.25, 95 % CI = 1.27-3.96, p = 0.005 in women). Gender differences were demonstrated in the association of individual ten depressive symptoms with cognitive impairment: men who felt lonely were more likely to have cognitive impairment (OR = 1.24, 95 % CI = 1.06-1.47, p = 0.010), while women who slept poorly were more likely to have cognitive impairment (OR = 1.42, 95 % CI = 1.16-1.74, p = 0.001).

CONCLUSION

Results indicate a stronger association between severe depressive symptoms and cognitive impairment among older Chinese males. Our study suggests that reducing loneliness can help prevent cognitive impairment in older men, and improving sleep quality can help improve cognitive function in older women.

The Worst of Times: Depressive Symptoms Among Racialized Groups Living With Dementia and Cognitive Impairment During the COVID-19 Pandemic

Objective: To explore differences in depressive symptoms for older adults (Black, Latinx, and White) by cognitive status during the 2020 COVID-19 pandemic. Methods: Data from the Health and Retirement Study identified older adults as cognitively normal, cognitively impaired without dementia (CIND), and persons living with dementia (PLWD). Multiple linear regression analyses examined associations between cognitive status and depressive symptoms among these racialized groups. Results: Compared to the cognitively normal older adults racialized as Black, those with CIND reported higher depressive symptoms during the pandemic (overall and somatic) and PLWD had higher somatic symptoms (p < .01). Older adults racialized as White with CIND reported higher somatic (p < .01) symptoms compared to cognitively normal older adults racialized as White. Discussion: The COVID-19 pandemic was a challenging event among older adults racialized as Black with CIND and PLWD. Future studies should examine if these depressive symptoms persist over time.

Disruptive and complementary effects of depression symptoms on spontaneous brain activity in the subcortical vascular mild cognitive impairment

Background

Although depression symptoms are commonly reported in patients with subcortical vascular mild cognitive impairment (svMCI), their impact on brain functions remains largely unknown, with diagnoses mainly dependent on behavioral assessments.

Methods

In this study, we analyzed resting-state fMRI data from a cohort of 34 svMCI patients, comprising 18 patients with depression symptoms (svMCI+D) and 16 patients without (svMCI-D), along with 34 normal controls (NC). The study used the fraction of the amplitude of low-frequency fluctuations (fALFF), resting-state functional connectivity, correlation analyses, and support vector machine (SVM) techniques.

Results

The fALFF of the right cerebellum (CERE.R) differed among the svMCI+D, svMCI-D, and NC groups. Specifically, the regional mean fALFF of CERE. R was lower in svMCI-D patients compared to NC but higher in svMCI+D patients compared to svMCI-D patients. Moreover, the adjusted fALFF of CERE. R showed a significant correlation with Montreal Cognitive Assessment (MOCA) scores in svMCI-D patients. The fALFF of the right orbital part of the superior frontal gyrus was significantly correlated with Hamilton Depression Scale scores in svMCI+D patients, whereas the fALFF of the right postcingulate cortex (PCC.R) showed a significant correlation with MOCA scores in svMCI-D patients. Furthermore, RSFC between PCC. R and right precuneus, as well as between CERE. R and the right lingual gyrus (LING.R), was significantly reduced in svMCI-D patients compared to NC. In regional analyses, the adjusted RSFC between PCC. R and PreCUN. R, as well as between CERE. R and LING. R, was decreased in svMCI-D patients compared to NC but increased in svMCI+D patients compared to svMCI-D. Further SVM analyses achieved good performances, with an area under the curve (AUC) of 0.82 for classifying svMCI+D, svMCI-D, and NC; 0.96 for classifying svMCI+D and svMCI-D; 0.82 for classifying svMCI+D and NC; and 0.92 for classifying svMCI-D and NC.

Conclusion

The study revealed disruptive effects of cognitive impairment, along with both disruptive and complementary effects of depression symptoms on spontaneous brain activity in svMCI. Moreover, these findings suggest that the identified features might serve as potential biomarkers for distinguishing between svMCI+D, svMCI-D, and NC, thereby guiding clinical treatments such as transcranial magnetic stimulation for svMCI.

Proteogenomic signature of risk of Alzheimer's disease and related dementia risk in individuals with a history of major depression disorder

The mechanisms linking a history of major depressive disorder (MDD) to an increased risk of Alzheimer's disease and related dementia (ADRD) are not fully understood. Using the UK Biobank available proteomic and genomic data, we evaluated the biological mechanisms linking both conditions. In participants with a history of MDD at baseline (n=3,615), we found that plasma levels of NfL, GFAP, PSG1 were associated with higher risk (HR=1.38; 1.37; 1.34, respectively; all adjusted p-values<0.05), while VGF, GET3, and HPGDS were associated with lower risk of incident ADRD (n=150) (HR=0.73; 0.71; 0.66, respectively; all adjusted p-values<0.05) during a mean follow-up of 13.7 years (SD=2.2). Two-sample Mendelian randomization analysis using cis-pQTLs genetic instruments revealed that a lower protein expression of apolipoprotein E and higher IL-10 receptor subunit B were causally linked to incident ADRD. Finally, we developed a Proteomic Risk Score (PrRSMDD-ADRD), which showed strong discriminative power (C-statistic = 0.84) to identify participants with MDD that developed ADRD upon follow-up. In addition to demonstrating an association between plasma proteins associated with inflammation and future ADRD risk in individuals with MDD, our findings include an element of causality using Mendelian Randomization (MR) and PrRSMDD-ADRD can be useful to identify individuals with the highest risk to develop ADRD in a highly vulnerable population.

Feasibility of training family caregivers of people living with dementia online to deliver life review depression intervention at home

OBJECTIVES

To alleviate the high prevalence of depressive symptoms and dementia in older Americans (≥65 years), we developed a depression intervention, Caregiver-Provided Life Review (C-PLR), and taught family caregivers life review skills online compared to a synchronous group virtual training, and examined the feasibility and delivery impact (N = 20 dyads).

METHOD

In a cross-sectional, mixed-methods dyadic design, we recruited family caregiver-care recipient dyads nationwide, collected the pre- and post-intervention measures on care recipients' depression (primary outcome), life satisfaction, caregivers' burden, caregiving rewards, and dyads' relationship quality (secondary outcomes), and compared them using t-tests. We took fidelity scores to measure caregivers' feasibility of delivering life reviews adhering to the protocol.

RESULTS

Care recipients' depressive symptoms declined significantly following the C-PLR intervention (p = 0.034) and caregivers' rewards increased from the pre- to post-period (p = 0.019). Caregivers' qualitative interviews supported the quantitative results that online-trained caregivers' ability to deliver the intervention with high adherence to protocol (15.9 ± 0.27 out of 16) without increasing caregiver burden.

CONCLUSION

This pilot study suggested that the C-PLR could make a positive impact on both caregivers' and care recipients' mental health. This innovative, cost-effective, and easily implemented activity can be used by any dyad regardless of whether they have any health-related deficits.

Predicting the severity of mood and neuropsychiatric symptoms from digital biomarkers using wearable physiological data and deep learning

Neuropsychiatric symptoms (NPS) and mood disorders are common in individuals with mild cognitive impairment (MCI) and increase the risk of progression to dementia. Wearable devices collecting physiological and behavioral data can help in remote, passive, and continuous monitoring of moods and NPS, overcoming limitations and inconveniences of current assessment methods. In this longitudinal study, we examined the predictive ability of digital biomarkers based on sensor data from a wrist-worn wearable to determine the severity of NPS and mood disorders on a daily basis in older adults with predominant MCI. In addition to conventional physiological biomarkers, such as heart rate variability and skin conductance levels, we leveraged deep-learning features derived from physiological data using a self-supervised convolutional autoencoder. Models combining common digital biomarkers and deep features predicted depression severity scores with a correlation of r = 0.73 on average, total severity of mood disorder symptoms with r = 0.67, and mild behavioral impairment scores with r = 0.69 in the study population. Our findings demonstrated the potential of physiological biomarkers collected from wearables and deep learning methods to be used for the continuous and unobtrusive assessments of mental health symptoms in older adults, including those with MCI. TRIAL REGISTRATION: This trial was registered with ClinicalTrials.gov (NCT05059353) on September 28, 2021, titled "Effectiveness and Safety of a Digitally Based Multidomain Intervention for Mild Cognitive Impairment".

Home-based, Remotely Supervised, 6-Week tDCS in Patients With Both MCI and Depression: A Randomized Double-Blind Placebo-Controlled Trial

As depressive symptom is considered a prodrome, a risk factor for progression from mild cognitive impairment (MCI) to dementia, improving depressive symptoms should be considered a clinical priority in patients with MCI undergoing transcranial direct current stimulation (tDCS) intervention. We aimed to comprehensively evaluate the efficacy of the home-based and remotely monitored tDCS in patients with both MCI and depression, by integrating cognitive, psychological, and electrophysiological indicators. In a 6-week, randomized, double blind, and sham-controlled study, 37 community-dwelling patients were randomly assigned to either an active or a sham stimulation group, and received 30 home-based sessions of 2 mA tDCS for 30 min with the anode located over the left and cathode over the right dorsolateral prefrontal cortex. We measured depressive symptoms, neurocognitive function, and resting-state electroencephalography. In terms of effects of both depressive symptoms and cognitive functions, active tDCS was not significantly different from sham tDCS. However, compared to sham stimulation, active tDCS decreased and increased the activation of delta and beta frequencies, respectively. Moreover, the increase in beta activity was correlated with the cognitive enhancement only in the active group. It was not possible to reach a definitive conclusion regarding the efficacy of tDCS on depression and cognition in patients with both MCI and depression. Nevertheless, the relationship between the changes of electrophysiology and cognitive performance suggests potential neuroplasticity enhancement implicated in cognitive processes by tDCS.

Effects of Phytoncide Fragrance on Resting-State Brain Activity in Mild Cognitive Impairment: A Randomized Double-Blind Controlled Study

Introduction: The therapeutic potential of phytoncide fragrances may be optimal for patients with mild cognitive impairment (MCI) that display complex symptomatology. This study aimed to explore the clinical value of phytoncide by evaluating its electrophysiological effects in patients with MCI. Materials and Methods: This was a double-blind, randomized controlled trial. A total of 24 community-dwelling patients were randomly assigned to either a phytoncide or no-odor group. Participants wore a dental mask, for 30 min at rest that had either the fragrance stimulus or water added to it. The quantitative electroencephalography (EEG) during the resting state was recorded before and after a single intervention. Results: There were significant interaction effects in absolute EEG-power values in the occipital (F = 6.52, p = 0.018) and parietal (F = 5.41, p = 0.030) left hemisphere at β frequency. Phytoncide odor significantly decreased low and high β activity in the occipital (corrected p = 0.009) and parietal (corrected p = 0.047) left hemisphere, respectively. In source localization, phytoncide odor significantly decreased deep source activation in the left inferior and middle frontal gyri at β 2 frequency band compared with the no-odor group (threshold = 4.25, p < 0.05). Conclusions: Reductions in β, indicative of anxiety, depression, and stress, suggest relief from emotion-related symptoms that are common in patients with MCI. Trial Registration: Clinical Trials Registry Korea (registration: KCT0007317).

Healthy aging meta-analyses and scoping review of risk factors across Latin America reveal large heterogeneity and weak predictive models

Models of healthy aging are typically based on the United States and Europe and may not apply to diverse and heterogeneous populations. In this study, our objectives were to conduct a meta-analysis to assess risk factors of cognition and functional ability across aging populations in Latin America and a scoping review focusing on methodological procedures. Our study design included randomized controlled trials and cohort, case-control and cross-sectional studies using multiple databases, including MEDLINE, the Virtual Health Library and Web of Science. From an initial pool of 455 studies, our meta-analysis included 38 final studies (28 assessing cognition and 10 assessing functional ability, n = 146,000 participants). Our results revealed significant but heterogeneous effects for cognition (odds ratio (OR) = 1.20, P = 0.03, confidence interval (CI) = (1.0127, 1.42); heterogeneity: I2 = 92.1%, CI = (89.8%, 94%)) and functional ability (OR = 1.20, P = 0.01, CI = (1.04, 1.39); I2 = 93.1%, CI = (89.3%, 95.5%)). Specific risk factors had limited effects, especially on functional ability, with moderate impacts for demographics and mental health and marginal effects for health status and social determinants of health. Methodological issues, such as outliers, inter-country differences and publication bias, influenced the results. Overall, we highlight the specific profile of risk factors associated with healthy aging in Latin America. The heterogeneity in results and methodological approaches in studying healthy aging call for greater harmonization and further regional research to understand healthy aging in Latin America.

Association of Depression and Cognitive Performance in US Older Adults: A Secondary Analysis of Cross-Sectional Data Using NHANES 2013-2014

INTRODUCTION

Depression has been associated with cognitive performance, but whether sociodemographic and clinical characteristics might influence this association is not well elaborated. This study aimed to further explore this relationship in older adults.

METHODS

This cross-sectional study is based on data from the National Health and Nutrition Examination Survey (NHANES) 2013-2014. A total of 1,433 individuals with complete information on depressive symptoms and cognitive function variables were included in this study. Patient Health Questionnaire 9 (PHQ-9) score ≥10 as the cutoff to identify cases of depression in our study. We defined poor cognitive performance as a composite cognitive score <47. Logistic regression models were used to examine the association of depression with cognitive performance (model 1). We progressively adjusted the covariates as confounders (model 2: model 1 + age, and gender; model 3: model 2 + race, education level, family income, drinking, and smoking; model 4: model 3 + overweight, arthritis, hyperlipidemia, diabetes, hypertension, heart failure, coronary heart disease, heart attack, stroke, and cancer). We then conducted subgroup, interaction, and restricted cubic spline (RCS) analyses to examine this association.

RESULTS

The prevalence of poor cognitive performance was 36.6% (53/145) in the depression group and 14.1% (182/1,288) in the non-depression group. In the fully adjusted model, depression was significantly associated with poor cognitive performance (adjusted odds ratio: 2.25; 95% confidence interval: 1.31-3.81). The results were robust to sensitivity analyses. Gender and education level may modify the association between depression and poor cognitive performance. RCS analysis revealed that the PHQ-9 score was related to poor cognitive performance in a nonlinear manner (p for nonlinearity <0.001), and exhibited a J-shaped curve.

CONCLUSION

Depression is associated with poor cognitive performance in US older adults. Early recognition and treatment of depression may be potential intervention strategies to protect cognitive health.

From Mild Cognitive Impairment to Dementia: The Impact of Comorbid Conditions on Disease Conversion

The conversion from mild cognitive impairment (MCI) to dementia is influenced by several factors, including comorbid conditions such as metabolic and vascular diseases. Understanding the impact of these comorbidities can help in the disease management of patients with a higher risk of progressing to dementia, improving outcomes. In the current study, we aimed to analyze data from a large cohort of MCI (n = 188) by principal component analysis (PCA) and cluster analysis (CA) to classify patients into distinct groups based on their comorbidity profile and to predict the risk of conversion to dementia. From our analysis, four clusters emerged. CA showed a significantly higher rate of disease progression for Cluster 1, which was predominantly characterized by extremely high obesity and diabetes compared to other clusters. In contrast, Cluster 3, which was defined by a lower prevalence of all comorbidities, had a lower conversion rate. Cluster 2, mainly including subjects with traumatic brain injuries, showed the lowest rate of conversion. Lastly, Cluster 4, including a high load of hearing loss and depression, showed an intermediate risk of conversion. This study underscores the significant impact of specific comorbidity profiles on the progression from MCI to dementia, highlighting the need for targeted interventions and management strategies for individuals with these comorbidity profiles to potentially delay or prevent the onset of dementia.

Effectiveness of a mobile application for independent computerized cognitive training in patients with mild cognitive impairment: study protocol for the NeNaE Study, a randomized controlled trial

BACKGROUND

Mild cognitive impairment (MCI) involves cognitive decline beyond typical age-related changes, but without significant daily activity disruption. It can encompass various cognitive domains as the causes of MCI are diverse. MCI as well as frequent comorbid neuropsychiatric conditions like depression and anxiety affect individuals' quality of life. Early interventions are essential, and computerized cognitive training (cCT) is an established treatment method. This paper presents the protocol for the NeuroNation MED Effectiveness Study, evaluating the self-administered mobile cCT intervention ("NeuroNation MED") in individuals with MCI to assess training effects on cognitive domains, health competence, neuropsychiatric symptoms, psychological well-being, and the general application usability.

METHODS

This study protocol presents a single-blinded multicenter randomized controlled trial that will be carried out in six study centers in Germany and Luxembourg. We included adults with MCI (existing F06.7 ICD-10-GM diagnosis and TICS ≥ 21 and ≤ 32). The intervention group will use a mobile, multi-domain cCT ("NeuroNation MED") for 12 weeks. Meanwhile, the wait list control group will receive standard medical care or no care. The eligibility of volunteers will be determined through a telephone screening. After completion of the baseline examination, patients will be randomly assigned to one of the experimental conditions in a 2:1 ratio. In total, 286 participants will be included in this study. The primary outcome is the change of cognitive performance measured by the index score of the screening module of the Neuropsychological Assessment Battery. Secondary outcomes are changes in the Cognitive Failures Questionnaire, Hospital Anxiety and Depression Scale, Health-49, Health Literacy Questionnaire, among others. All of the primary and secondary outcomes will be assessed at baseline and after the 12-week post-allocation period. Furthermore, the intervention group will undergo an assessment of the System Usability Scale, and the training data of the NeuroNation MED application will be analyzed.

DISCUSSION

This study aims to assess the effectiveness of a mobile self-administered cCT in enhancing cognitive abilities among individuals diagnosed with MCI. Should the findings confirm the effectiveness of the NeuroNation MED app, it may confer possible benefits for the care management of patients with MCI, owing to the accessibility, cost-effectiveness, and home-based setting it provides. Specifically, the cCT program could provide patients with personalized cognitive training, educational resources, and relaxation techniques, enabling participants to independently engage in cognitive training sessions at home without further supervision.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00025133. Registered on November 5, 2021.

Speech Emotion Recognition in People at High Risk of Dementia

Background and Purpose

The emotions of people at various stages of dementia need to be effectively utilized for prevention, early intervention, and care planning. With technology available for understanding and addressing the emotional needs of people, this study aims to develop speech emotion recognition (SER) technology to classify emotions for people at high risk of dementia.

Methods

Speech samples from people at high risk of dementia were categorized into distinct emotions via human auditory assessment, the outcomes of which were annotated for guided deep-learning method. The architecture incorporated convolutional neural network, long short-term memory, attention layers, and Wav2Vec2, a novel feature extractor to develop automated speech-emotion recognition.

Results

Twenty-seven kinds of Emotions were found in the speech of the participants. These emotions were grouped into 6 detailed emotions: happiness, interest, sadness, frustration, anger, and neutrality, and further into 3 basic emotions: positive, negative, and neutral. To improve algorithmic performance, multiple learning approaches were applied using different data sources-voice and text-and varying the number of emotions. Ultimately, a 2-stage algorithm-initial text-based classification followed by voice-based analysis-achieved the highest accuracy, reaching 70%.

Conclusions

The diverse emotions identified in this study were attributed to the characteristics of the participants and the method of data collection. The speech of people at high risk of dementia to companion robots also explains the relatively low performance of the SER algorithm. Accordingly, this study suggests the systematic and comprehensive construction of a dataset from people with dementia.

Targeting Abnormal Tau Phosphorylation for Alzheimer's Therapeutics

Alzheimer's disease (AD) is a widespread neurodegenerative disorder characterized by progressive memory and cognitive decline, posing a formidable public health challenge. This review explores the intricate interplay between two pivotal players in AD pathogenesis: β-amyloid (Aβ) and tau protein. While the amyloid cascade theory has long dominated AD research, recent developments have ignited debates about its centrality. Aβ plaques and tau NFTs are hallmark pathologies in AD. Aducanumab and lecanemab, monoclonal antibodies targeting Aβ, have been approved, albeit amidst controversy, raising questions about the therapeutic efficacy of Aβ-focused interventions. On the other hand, tau, specifically its hyperphosphorylation, disrupts microtubule stability and contributes to neuronal dysfunction. Various post-translational modifications of tau drive its aggregation into NFTs. Emerging treatments targeting tau, such as GSK-3β and CDK5 inhibitors, have shown promise in preclinical and clinical studies. Restoring the equilibrium between protein kinases and phosphatases, notably protein phosphatase-2A (PP2A), is a promising avenue for AD therapy, as tau is primarily regulated by its phosphorylation state. Activation of tau-specific phosphatases offers potential for mitigating tau pathology. The evolving landscape of AD drug development emphasizes tau-centric therapies and reevaluation of the amyloid cascade hypothesis. Additionally, exploring the role of neuroinflammation and its interaction with tau pathology present promising research directions.

Effect of emotional stimulus on response inhibition in people with mild cognitive impairment: an event-related potential study

Background

A few studies are emerging to explore the issue of how aging promotes emotional response inhibition. However, there is a lack of empirical study concerning the impact of pathological cognitive impairment on emotional response inhibition. The present study investigated the effect of emotion on response inhibition in people with mild cognitive impairment, the stage of cognitive impairment before dementia.

Methods

We used two emotional stop-signal tasks to explore whether the dual competition framework considering limited cognitive resources could explain the relationship between emotion and response inhibition in mild cognitive impairment.

Results

The results showed that negative emotions prolonged N2 latency. The Go trial accuracy was reduced in the high-arousal negative conditions and the stop-signal reaction time was prolonged under high-arousal conditions. This study also verified impaired response inhibition in mild cognitive impairment and found that negative emotions prolonged P3 latency in mild cognitive impairment.

Conclusion

Emotional information interferes with response inhibition in mild cognitive impairment populations, possibly because emotional information captures more attentional resources, thus interfering with response inhibition that relies on common-pool resources.

Depressive symptoms in the entire spectrum of cognitive ageing in Greece: evidence from the Hellenic Longitudinal Investigation of Aging and Diet (HELIAD)

OBJECTIVES

To study (i) the prevalence of mild and moderate-to-severe depressive symptoms in the entire spectrum of cognitive ageing in Greece and (ii) the relationship between these symptoms and demographic and clinical data.

METHODS

The study was based on the randomly selected cohort of the Hellenic Longitudinal Investigation of Aging and Diet (HELIAD). Depressive symptoms were assessed with the 15-item version of the Geriatric Depression Scale. Participants also received a comprehensive neuropsychological assessment, while the clinical diagnoses of dementia and mild cognitive impairment were established according to international diagnostic criteria. Statistical analyses relied on comparison tests and a logistic (proportional odds) ordinal regression model.

RESULTS

Depressive symptoms were detected in 19.5% of the 1936 study participants, while 11.3% of both people with MCI and dementia had moderate-to-severe depressive symptoms. The regression model revealed that older adults with more severe depressive symptoms were more likely female, cognitively impaired, less educated, were treated with psychotropic medication and lived in Attica versus Thessaly.

CONCLUSIONS

Since depressive symptoms were detected in almost one in five older adults, healthcare professionals in Greece should safeguard the timely detection and effective treatment of such symptoms and the post-diagnostic care of older adults with depression.

Association of depressive symptoms and dementia among middle-aged and elderly community-dwelling adults: Results from the China Health and Retirement Longitudinal Study (CHARLS)

BACKGROUND

There has been a long-standing debate on whether depressive symptoms are associated with dementia. The aim of this study was to examine whether depressive symptoms were associated with a high risk for dementia in Chinese adults.

METHODS

A total of 13,426 Chinese adults (≥45 years old) from the China Health and Retirement Longitudinal Study (CHARLS) baseline were selected for analysis. Depressive symptoms were assessed by the Center for Epidemiologic Studies Depression Scale (CESD-10). Dementia was assessed by the Community Screening Instrument for Dementia (CSI-D). When using linear regression for sensitivity analysis, there is still a correlation between depressive symptoms and dementia.

RESULTS

Of the 13,426 respondents, the mean (SD) age was 60 (10) years old. The prevalence of depressive symptoms and dementia among participants was 38 % (n = 945) and 18.3 % (n = 2457), respectively. After fully adjusted for demographic factors, health behavior and psychological factors, living and working conditions factors, social network factors, and social policy factors, the cross-sectional analyses showed that depressive symptoms had an increased risk of dementia (OR = 1.390, 95%CI: 1.253-1.543), compared with those without depressive symptoms. In addition, sensitivity analyses of the association between depressive symptoms and dementia were unchanged when reanalyzing using linear regression.

CONCLUSIONS

In this study, depression symptoms may be associated with dementia. Regardless of whether depressive symptoms acts as a dementia risk factor or an early symptom, monitoring depressive symptoms is crucial to watch for potential dementia onset.

Potentially Modifiable Risk Factors for Dementia and Mild Cognitive Impairment: An Umbrella Review and Meta-Analysis

INTRODUCTION

The prevalence of mild and major neurocognitive disorders (NCDs), also referred to as mild cognitive impairment and dementia, is rising globally. The prevention of NCDs is a major global public health interest. We sought to synthesize the literature on potentially modifiable risk factors for NCDs.

METHODS

We conducted an umbrella review using a systematic search across multiple databases to identify relevant systematic reviews and meta-analyses. Eligible reviews examined potentially modifiable risk factors for mild or major NCDs. We used a random-effects multi-level meta-analytic approach to synthesize risk ratios for each risk factor while accounting for overlap in the reviews. We further examined risk factors for major NCD due to two common etiologies: Alzheimer's disease and vascular dementia.

RESULTS

A total of 45 reviews with 212 meta-analyses were synthesized. We identified fourteen broadly defined modifiable risk factors that were significantly associated with these disorders: alcohol consumption, body weight, depression, diabetes mellitus, diet, hypertension, less education, physical inactivity, sensory loss, sleep disturbance, smoking, social isolation, traumatic brain injury, and vitamin D deficiency. All 14 factors were associated with the risk of major NCD, and five were associated with mild NCD. We found considerably less research for vascular dementia and mild NCD.

CONCLUSION

Our review quantifies the risk associated with 14 potentially modifiable risk factors for mild and major NCDs, including several factors infrequently included in dementia action plans. Prevention strategies should consider approaches that reduce the incidence and severity of these risk factors through health promotion, identification, and early management.

Translation and Adaptation of Cognistat in Hindi Language: For Computerized Evaluation of Cognitive Functioning

OBJECTIVE

Cognitive assessment is a crucial element of the mental health screening process. However, there is a lack of culturally appropriate cognitive screening tools for the Hindi-speaking aging population in India. We aimed to translate and culturally tailor the English version of the computerized Cognistat test for the Hindi-speaking aging population.

METHOD

The computer-based Cognistat Assessment System was culturally adapted for the North Indian Hindi-speaking population. Participants with mild cognitive impairment (MCI) (n = 30), depression (n = 30), and healthy control (n = 30) groups between the age range of 50 and 83 years were assessed using the translated version of the tool. The group differences were analyzed using analysis of variance, multivariate analysis of variance, Tukey's post hoc analysis for continuous variables, and Fisher's exact test for categorical variables. The correlation between the Cognistat domains was analyzed using Pearson's correlation, and test reliability was assessed using Cronbach's alpha.

RESULTS

The MCI group had significantly lower scores as compared with the depression and control groups on orientation, language, repetition, and calculation domain tasks. For attention and construction tasks, the MCI group had lower scores than the control group. MCI group scores were significantly lower than the control group on naming domain. The Hindi version of the test was reliable for the Hindi-speaking aging population.

CONCLUSIONS

Cognistat Hindi can be used by trained healthcare professionals with Hindi-speaking populations for culturally tailored primary evaluation of cognitive difficulties. Future research should focus on further validation and assessment of its properties.

A change in social participation affects cognitive function in middle-aged and older Chinese adults: analysis of a Chinese longitudinal study on aging (2011-2018)

Background

One of the biggest challenges facing older adults is cognitive decline and social participation has always been considered a protective factor. However, it is not clear whether social participation predicts cognitive function in this population, rather than depressive symptoms, self-reported health, and activities of daily life, with sufficient capacity to detect unique effects.

Methods

This study included adults aged 45 and above in China (N = 5,258) who participated in a large national older adult health survey and provided data from 2011, 2013, 2015, and 2018. The unique associations between the predictors of social participation and cognitive function over time and context were evaluated in the Latent Growth Model (LGM).

Results

Among the 5,258 participants in our study, an overall cognitive decline was observed. Social participation predicts two dimensions of cognitive function, with a degree of impact comparable to depressive symptoms, self-reported health, and activities of daily life. Among them, social participation exhibits a noteworthy prognostic impact on episodic memory during the same period. The regression coefficient is approximately 0.1 (p < 0.05) after controlling other mixed variables (depressive symptoms, self-reported health, and activities of daily life). In contrast, social participation is also a significant predictor of mental intactness in the same period, with a regression coefficient of 0.06 (p < 0.05), even if all mixed variables are controlled.

Conclusion

Over time, the correlation strength of social participation is comparable to other recognized cognitive function prediction indicators, indicating that promoting social participation among middle-aged and older Chinese adults is a meaningful way to improve cognitive function degradation, which has important policy and practical significance.

Navigating the dementia landscape: Biomarkers and emerging therapies

The field of dementia research has witnessed significant developments in our understanding of neurodegenerative disorders, with a particular focus on Alzheimer's disease (AD) and Frontotemporal Dementia (FTD). Dementia, a collection of symptoms arising from the degeneration of brain cells, presents a significant healthcare challenge, especially as its prevalence escalates with age. This abstract delves into the complexities of these disorders, the role of biomarkers in their diagnosis and monitoring, as well as emerging neurophysiological insights. In the context of AD, anti-amyloid therapy has gained prominence, aiming to reduce the accumulation of amyloid-beta (Aβ) plaques in the brain, a hallmark of the disease. Notably, Leqembi recently received full FDA approval, marking a significant breakthrough in AD treatment. Additionally, ongoing phase 3 clinical trials are investigating novel therapies, including Masitinib and NE3107, focusing on cognitive and functional improvements in AD patients. In the realm of FTD, research has unveiled distinct neuropathological features, including the involvement of proteins like TDP-43 and progranulin, providing valuable insights into the diagnosis and management of this heterogeneous condition. Biomarkers, including neurofilaments and various tau fragments, have shown promise in enhancing diagnostic accuracy. Neurophysiological techniques, such as transcranial magnetic stimulation (TMS), have contributed to our understanding of AD and FTD. TMS has uncovered unique neurophysiological signatures, highlighting impaired plasticity, hyperexcitability, and altered connectivity in AD, while FTD displays differences in neurotransmitter systems, particularly GABAergic and glutamatergic circuits. Lastly, ongoing clinical trials in anti-amyloid therapy for AD, such as Simufilam, Solanezumab, Gantenerumab, and Remternetug, offer hope for individuals affected by this devastating disease, with the potential to alter the course of cognitive decline. These advancements collectively illuminate the evolving landscape of dementia research and the pursuit of effective treatments for these challenging conditions.

Mild Behavioral Impairment and Cerebrovascular Profiles Are Associated with Early Cognitive Impairment in a Community-Based Southeast Asian Cohort

Background

Mild behavioral impairment (MBI) is one of the earliest observable changes when a person experiences cognitive decline and could be an early manifestation of underlying Alzheimer's disease neuropathology. Limited attention has been given to investigating the clinical applicability of behavioral biomarkers for detection of prodromal dementia.

Objective

This study compared the prevalence of self-reported MBI and vascular risk factors in Southeast Asian adults to identify early indicators of cognitive impairment and dementia.

Methods

This cohort study utilized baseline data from the Biomarkers and Cognition Study, Singapore (BIOCIS). 607 participants were recruited and classified into three groups: cognitively normal (CN), subjective cognitive decline (SCD), and mild cognitive impairment (MCI). Group comparisons of cognitive-behavioral, neuroimaging, and blood biomarkers data were applied using univariate analyses. Multivariate logistic regression analyses were conducted to investigate the association between cerebrovascular disease, vascular profiles, and cognitive impairment.

Results

SCD had significantly higher depression scores and poorer quality of life (QOL) compared to CN. MCI had significantly higher depression scores; total MBI symptoms, MBI-interest, MBI-mood, and MBI-beliefs; poorer sleep quality; and poorer QOL compared to CN. Higher Staals scores, glucose levels, and systolic blood pressure were significantly associated with MCI classification. Fasting glucose levels were significantly correlated with depression, anxiety, MBI-social, and poorer sleep quality.

Conclusions

The results reflect current research that behavioral changes are among the first symptoms noticeable to the person themselves as they begin to experience cognitive decline. Self-reported questionnaires may aid in early diagnoses of prodromal dementia. Behavioral changes and diabetes could be potential targets for preventative healthcare for dementia.

Relationship between serum apolipoprotein B levels and depressive symptoms in elderly Chinese patients with mild cognitive impairment: A large-scale cross-sectional and five-year follow-up study

BACKGROUND

Patients with mild cognitive impairment (MCI) often have depressive symptoms. The purpose of this study was to investigate the effects of depressive symptoms on lipid metabolism and future cognitive function in patients with MCI.

METHODS

A total of 1014 patients with MCI were included. Their demographic data, clinical data, and lipid parameters were collected. Meanwhile, they also completed a series of scale assessments, including Geriatric depression scale (GDS), Ability of Daily Living (ADL), Montreal cognitive assessment (MoCA) and Block Design Test (BDT). Then these patients were also followed for five years.

RESULTS

Patients with depressive symptoms had lower serum apolipoprotein B (ApoB) levels, lower BDT scores and higher ADL scale scores. Correlation analysis showed that GDS was significantly associated with BDT and ADL. Moreover, logistic regression analysis found that ApoB was associated with depressive symptoms. Cox regression analysis showed that only baseline MoCA scores could predict the risk of future MCI transition to dementia.

CONCLUSIONS

Our results suggest low serum ApoB levels may be associated with depressive symptoms in patients with MCI. However, depressive mood or lipids alone may not predict the risk of MCI transition to dementia.

Relationship Between Cognitive Impairment and Depression Among Middle Aged and Older Adults in Primary Care

Objectives: To determine rates of previously undetected cognitive impairment among patients with depression in primary care. Methods: Patients ages 55 and older with no documented history of dementia or mild cognitive impairment were recruited from primary care practices in New York City, NY and Chicago, IL (n = 855). Cognitive function was assessed with the Montreal Cognitive Assessment (MoCA) and depression with the Patient Health Questionnaire-8. Results: The mean age was 66.8 (8.0) years, 45.3% were male, 32.7% Black, and 29.2% Latinx. Cognitive impairment increased with severity of depression: 22.9% in persons with mild depression, 27.4% in moderate depression and 41.8% in severe depression (p = .0002). Severe depression was significantly associated with cognitive impairment in multivariable analysis (standardized β = -.11, SE = 0.33, p < .0001). Discussion: Depression was strongly associated with previously undetected cognitive impairment. Primary care clinicians should consider screening, or expand their screening, for both conditions.

Amyloid Pathology Modulates the Associations of Neuropsychiatric Symptoms with Cognitive Impairments and Neurodegeneration in Non-Demented Elderly

BACKGROUND

The associations between neuropsychiatric symptoms (NPSs) and Alzheimer's disease (AD) have been well-studied, yet gaps remain.

OBJECTIVE

We aimed to examine the associations of four subsyndromes (hyperactivity, psychosis, affective symptoms, and apathy) of NPSs with cognition, neurodegeneration, and AD pathologies.

METHODS

Totally 1,040 non-demented elderly (48.07% males) from the Alzheimer's Disease Neuroimaging Initiative (ADNI) were included. We assessed the relationships between NPSs and AD neuropathologies, cognition, neurodegeneration, and clinical correlates in cross-sectional and longitudinal via multiple linear regression, linear mixed effects, and Cox proportional hazard models. Causal mediation analyses were conducted to explore the mediation effects of AD pathologies on cognition and neurodegeneration.

RESULTS

We found that individuals with hyperactivity, psychosis, affective symptoms, or apathy displayed a poorer cognitive status, a lower CSF amyloid-β (Aβ) level and a higher risk of clinical conversion (p < 0.05). Hyperactivity and affective symptoms were associated with increasing cerebral Aβ deposition (p < 0.05). Except psychosis, the other three subsyndromes accompanied with faster atrophy of hippocampal volume (p < 0.05). Specific NPSs were predominantly associated with different cognitive domains decline through an 8-year follow-up (p < 0.05). Moreover, the relationships between NPSs and cognitive decline, neurodegeneration might be associated with Aβ, the mediation percentage varied from 6.05% to 17.51% (p < 0.05).

CONCLUSIONS

NPSs could be strongly associated with AD. The influences of NPSs on cognitive impairments, neurodegeneration might be partially associated with Aβ.

The effect of receptive music therapy on older adults with mild cognitive impairment and depression: a randomized controlled trial

This study aims to evaluate the effects of a receptive music therapy intervention on cognitive functions and depressive symptoms in older adults with MCI. A randomized controlled trial was conducted in Wuhan, China. Eighty older adults, over 65, who had MCI and depression symptoms were randomly divided into the intervention and control groups. The intervention group received usual nursing care plus receptive music therapy intervention four times a week, for eight weeks; the control group received usual nursing care during the same period. The linear regression analysis was used to compare the difference between groups. There was a significant difference in the intervention group for the pre-intervention and post-intervention scores of cognitive function and depression. There was no significant difference in the control group before and after the study period and a significant between-group difference in both cognitive function and depression. In conclusion, receptive music therapy intervention significantly improved cognitive function and reduced depressive symptoms in older adults with MCI. It could be widely used in communities and nursing homes to improve the quality of life of older adults.

The relationship between TGF-β1 and cognitive function in the brain

Transforming growth factor-β1 (TGF-β1), a multifunctional cytokine, plays a pivotal role in synaptic formation, plasticity, and neurovascular unit regulation. This review highlights TGF-β1's potential impact on cognitive function, particularly in the context of neurodegenerative disorders. However, despite the growing body of evidence, a comprehensive understanding of TGF-β1's precise role remains elusive. Further research is essential to unravel the complex mechanisms through which TGF-β1 influences cognitive function and to explore therapeutic avenues for targeting TGF-β1 in neurodegenerative conditions. This investigation sheds light on TGF-β1's contribution to cognitive function and offers prospects for innovative treatments and interventions. This review delves into the intricate relationship between TGF-β1 and cognitive function.

Epidemiology of neurocognitive disorders in adults from urban-marginalized areas: a door-to-door population-based study in Puente Piedra, Lima, Peru

Background

In Latin America (LA), the prevalence of dementia is expected to triple to 150 million people by 2050. The 2020 Lancet Commission report identified several modifiable dementia risk factors, yet few social and environmental factors, most relevant to vulnerable regions of LA, were highlighted in this report. We sought to assess the epidemiology of neurocognitive disorders (NCD) in Puente Piedra, one of the most socially and economically vulnerable districts of Lima, the capital of Peru.

Methodology

This was a cross-sectional door-to-door observational study that used two-stage household sampling. One young adult (30-59 years) and one older adult (>60 years) per household were enrolled. We collected demographic, clinical, and neurocognitive data. Addenbrooke's Cognitive Examination (young adults) and the RUDAS-PE (older adults) were used, classifying participants as cognitively normal, possible mild NCD, or possible major NCD.

Results

We enrolled 247 participants (median age 46 years; 67% female). One-fourth had not completed secondary school and more than 50% completed only secondary school. Most participants were housewives (46%) and 21% did not have health insurance. The overall prevalence of possible NCD was 30% (25.6 and 41.8% among younger adults and older adults, respectively). Among younger adults, those ages 55-59 years more frequently had NCD (70%) compared to younger age ranges. Among older adults, only 3 subjects (4.5%) had major NCD.

Conclusion

We found a high frequency of possible NCDs in a socially and economically vulnerable community in Lima, Peru, with younger adults showing levels of NCD higher than expected. Our findings support the need for health systems to incorporate cognitive screenings programs for NCD in younger ages. Future research on NCD would include younger populations, particularly in vulnerable communities.

Developing a machine learning model for detecting depression, anxiety, and apathy in older adults with mild cognitive impairment using speech and facial expressions: A cross-sectional observational study

BACKGROUND

Depression, anxiety, and apathy are highly prevalent in older people with preclinical dementia and mild cognitive impairment. These symptoms have also proven valuable in predicting the progression from mild cognitive impairment to dementia, enabling a timely diagnosis and treatment. However, objective and reliable indicators to detect and distinguish depression, anxiety, and apathy are relatively scarce.

OBJECTIVE

This study aimed to develop a machine learning model to detect and distinguish depression, anxiety, and apathy based on speech and facial expressions.

DESIGN

An observational, cross-sectional study design.

SETTING(S)

The memory outpatient department of a tertiary hospital.

PARTICIPANTS

319 older adults diagnosed with mild cognitive impairment.

METHODS

Depression, anxiety, and apathy were evaluated by the Public Health Questionnaire, General Anxiety Disorder, and Apathy Evaluation Scale, respectively. Speech and facial expressions of older adults with mild cognitive impairment were digitally captured using audio and video recording software. Open-source data analysis toolkits were utilized to extract speech, facial, and text features. The multiclass classification was used to develop classification models, and shapely additive explanations were used to explain the contribution of each feature within the model.

RESULTS

The random forest method was used to develop a multiclass emotion classification model, which performed well in classifying emotions with a weighted-average F1 score of 96.6 %. The model also demonstrated high accuracy, precision, and recall, with 87.4 %, 86.6 %, and 87.6 %, respectively.

CONCLUSIONS

The machine learning model developed in this study demonstrated strong classification performance in detecting and differentiating depression, anxiety, and apathy. This innovative approach combines text, audio, and video to provide objective methods for precise classification and remote monitoring of these symptoms in nursing practice.

REGISTRATION

This study was registered at the Chinese Clinical Trial Registry (registration number: ChiCTR1900023892; registration date: June 19th, 2019).

Effect of Tablet-based Cognitive Intervention on Cognition in Patients With Mild Cognitive Impairment: A Pilot Study

Background and Purpose

Growing evidence has shown that cognitive interventions can mitigate cognitive decline in patients with mild cognitive impairment (MCI). However, most previous cognitive interventions have been group-based programs. Due to their intrinsic limitations, group-based programs are not widely used in clinical practice. Therefore, we have developed a tablet-based cognitive intervention program. This preliminary study investigated the feasibility and effects of a 12-week structured tablet-based program on cognitive function in patients with MCI.

Methods

We performed a single-arm study on 24 patients with MCI. The participants underwent a tablet-based cognitive intervention program 5 times a week over a 12-week period. The primary outcome was changes in cognitive function, measured using the Korean version of the Consortium to Establish a Registry for Alzheimer's Disease Assessment Packet (CERAD-K). Outcomes were evaluated at baseline, within two weeks of the last program (post-intervention), and at the six-month follow-up session.

Results

The completion rate of the tablet-based program was 83.3% in patients with MCI. The program improved cognitive function based on the CERAD-K total score (p=0.026), which was maintained for at least three months (p=0.004). There was also an improvement in the depression scale score (p=0.002), which persisted for three months (p=0.027).

Conclusions

Our 12-week structured tablet-based program is feasible for patients with MCI. Furthermore, although further studies with a double-arm design are required, the program appears to be an effective strategy to prevent cognitive decline in patients with MCI.

Cognitive Impairment and the Associated Factors Among Older People in Rural Central Tanzania

AIM

This study examined the profile of cognitive impairment and associated factors among older people in rural central Tanzania.

METHODS

We conducted a cross-sectional study involving 462 community-dwelling older adults. We performed cognitive, psychosocial, and clinical assessments and face-to-face interviews with all older adults. Descriptive, bivariate and multivariate linear regression analyses were performed to determine the participant's cognitive performance and the associated factors.

RESULTS

The mean cognitive score on the Identification and Intervention for Dementia in Elderly Africans cognitive test was 11.04 (SD=2.89). Per the proposed cut-off scores to define probable and possible dementia, 13.2% of the population had probable dementia and another 13.9% had possible dementia. Increase in age was associated with poor cognitive performance (β=-0.076, 95% CI=-0.109 to -0.043, P<0.001); whereas male sex (β=0.989, 95% CI=0.333 to 1.645, P=0.003), higher educational attainment (β=2.575, 95% CI=0.557 to 4.594, P=0.013) and performance in instrumental activities of daily living (β=0.552, 95% CI=0.376 to 0.729, P<0.001) were associated with higher cognitive performance.

DISCUSSION

Older people in rural settings of central Tanzania have poor cognitive functions and are at high risk of further cognitive decline. Preventive and therapeutic programs for the affected older people are warranted to prevent further decline and maintain quality of life.

Psychosocial profiles within community-dwelling older adults with Mild Cognitive Impairment: A prevalence and latent profile analysis study

OBJECTIVES

Mild Cognitive Impairment (MCI) is an at-risk stage for dementia and accurate prevalence studies are lacking in Singapore. From the literature, it is evident that psychosocial factors increase the risk of conversion to dementia. In this study, we sought to establish the prevalence of MCI in Singapore and study the associated psychosocial factors using latent profile analysis.

METHOD

902 community-dwelling older adults, aged between 60 and 99 years old (Mage = 70.48 years), were recruited as part of the Community Health and Intergenerational Study (CHI). They completed neurocognitive assessments and questionnaires on depression and anxiety symptoms, quality of life, social support, satisfaction with life, and social connectivity. Petersen's criteria was used to diagnose MCI. Within the MCI sample, 166 subjects' psychosocial scores were entered into a latent profile analysis to identify profiles of psychosocial functioning.

RESULTS

The prevalence of MCI in our sample was 21.5%. They had significantly lower years of education and perceived social support and higher depressive symptoms than the normal ageing group. Three distinct profiles emerged within the MCI group corresponding to a positive (45.2%), neutral (38.5%), and negative (16.3%) pattern of psychosocial scores. These profiles did not differ significantly in terms of demographic or cognitive variables.

DISCUSSION

The three psychosocial profiles might reflect the differing implications of MCI on a person's well-being and the negative psychosocial profile might likely be most at risk of conversion to dementia. Future longitudinal studies are required to confirm these implications.

Association of subclinical depressive symptoms and sleep with cognition in the community-dwelling older adults

BACKGROUND

/Purpose: This study aimed to explore the association of subclinical depressive symptoms and sleep with cognition in community-dwelling Taiwanese older adults.

METHODS

This four-year prospective cohort study (2015-2019) included 379 participants aged 65 years or older from the annual senior health checkup program at National Taiwan University Hospital who were followed up two years later. Global and domain cognitive functions were assessed using validated neuropsychological tests. Depressive symptoms were evaluated using the Center for Epidemiologic Studies Depression (CES-D) Scale. Sleep quality was evaluated using the Pittsburg Sleep Quality Index (PSQI). Excessive daytime sleepiness was assessed using the Epworth Sleepiness Scale (ESS). Generalized linear mixed models were used to explore the associations of subclinical depressive symptoms and sleep variables with cognition, adjusting for important covariates. Stratification analyses were performed using the sleep variables.

RESULTS

Over time, depressive symptoms were associated with poor performance of memory (βˆ = 0.24, P = 0.04) and executive function (βˆ = -0.24, P = 0.03). Poor sleep quality (elevated PSQI score) was associated with poor memory performance (βˆ = -0.04 to -0.03, P < 0.05). Excessive daytime sleepiness (elevated ESS score) was associated with poor performance of memory (βˆ = -0.02, P < 0.05) and executive function (βˆ = -0.02, P = 0.001). At baseline, better sleep quality and no excessive daytime sleepiness were associated with better memory performance over time.

CONCLUSION

Subclinical depressive symptoms, worse sleep quality, and excessive daytime sleepiness were differentially associated with impairment of cognitive domains (mainly memory and executive function).

Pharmacologic treatment of depression in Alzheimer's disease

Major depressive disorder and Alzheimer's disease are common among older people, frequently co-occur and severely impact the quality of life. Unfortunately, data on the efficacy of pharmacologic treatment of depressive symptoms in patients with the neurodegenerative disease remain inconclusive. The heterogeneity of treatment study designs, from varying diagnostic specificity to diverse outcome measures, contributes to conflicting evidence across single trials and meta-analyses. In this literature review, we focus on commercially available products for antidepressant treatment in demented individuals and show how insights from randomized controlled trials could still guide and be aligned with common clinical practice.

Depressive Symptom Trajectories and Cognition Among Older American Couples: A Dyadic Perspective

OBJECTIVES

This study examined whether trajectories of depressive symptoms of one spouse are associated with the other spouse's memory.

METHODS

Longitudinal data from the Health and Retirement Study (2004-2016) were used (N = 5690 heterosexual couples). Latent-class growth analysis and structural equation models examined the actor and partner effects of depressive symptom trajectories on memory.

RESULTS

Four depressive symptom trajectories were identified (i.e., persistently low, increasing, decreasing, and persistently high). Compared to the low trajectory group, the increasing and persistently high trajectories were associated with worse memory for both men and women. While none of the wives' depressive symptom trajectories was significantly associated with husbands' memory (p > .05), husbands' decreasing trajectory was linked to wives' better memory (β = 0.498, 95% CI = 0.106, 0.890).

DISCUSSION

Older adults with increasing and persistently high depressive symptoms may experience worse memory. Psychosocial interventions targeting depressive symptoms among older men may be beneficial to their spouses' memory.

Cretan Aging Cohort-Phase III: Methodology and Descriptive Characteristics of a Long-Term Longitudinal Study on Predictors of Cognitive Decline in Non-Demented Elderly from Crete, Greece

Identifying modifiable factors that may predict long-term cognitive decline in the elderly with adequate daily functionality is critical. Such factors may include poor sleep quality and quantity, sleep-related breathing disorders, inflammatory cytokines and stress hormones, as well as mental health problems. This work reports the methodology and descriptive characteristics of a long-term, multidisciplinary study on modifiable risk factors for cognitive status progression, focusing on the 7-year follow-up. Participants were recruited from a large community-dwelling cohort residing in Crete, Greece (CAC; Cretan Aging Cohort). Baseline assessments were conducted in 2013-2014 (Phase I and II, circa 6-month time interval) and follow-up in 2020-2022 (Phase III). In total, 151 individuals completed the Phase III evaluation. Of those, 71 were cognitively non-impaired (CNI group) in Phase II and 80 had been diagnosed with mild cognitive impairment (MCI). In addition to sociodemographic, lifestyle, medical, neuropsychological, and neuropsychiatric data, objective sleep was assessed based on actigraphy (Phase II and III) and home polysomnography (Phase III), while inflammation markers and stress hormones were measured in both phases. Despite the homogeneity of the sample in most sociodemographic indices, MCI persons were significantly older (mean age = 75.03 years, SD = 6.34) and genetically predisposed for cognitive deterioration (APOE ε4 allele carriership). Also, at follow-up, we detected a significant increase in self-reported anxiety symptoms along with a substantial rise in psychotropic medication use and incidence of major medical morbidities. The longitudinal design of the CAC study may provide significant data on possible modifiable factors in the course of cognitive progression in the community-dwelling elderly.

Impact of mental disorders on clinical outcomes of physical diseases: an umbrella review assessing population attributable fraction and generalized impact fraction

Empirical evidence indicates a significant bidirectional association between mental disorders and physical diseases, but the prospective impact of men-tal disorders on clinical outcomes of physical diseases has not been comprehensively outlined. In this PRISMA- and COSMOS-E-compliant umbrella review, we searched PubMed, PsycINFO, Embase, and Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, up to March 15, 2022, to identify systematic reviews with meta-analysis that examined the prospective association between any mental disorder and clinical outcomes of physical diseases. Primary outcomes were disease-specific mortality and all-cause mortality. Secondary outcomes were disease-specific incidence, functioning and/or disability, symptom severity, quality of life, recurrence or progression, major cardiac events, and treatment-related outcomes. Additional inclusion criteria were further applied to primary studies. Random effect models were employed, along with I2 statistic, 95% prediction intervals, small-study effects test, excess significance bias test, and risk of bias (ROBIS) assessment. Associations were classified into five credibility classes of evidence (I to IV and non-significant) according to established criteria, complemented by sensitivity and subgroup analyses to examine the robustness of the main analysis. Statistical analysis was performed using a new package for conducting umbrella reviews (https://metaumbrella.org). Population attributable fraction (PAF) and generalized impact fraction (GIF) were then calculated for class I-III associations. Forty-seven systematic reviews with meta-analysis, encompassing 251 non-overlapping primary studies and reporting 74 associations, were included (68% were at low risk of bias at the ROBIS assessment). Altogether, 43 primary outcomes (disease-specific mortality: n=17; all-cause mortality: n=26) and 31 secondary outcomes were investigated. Although 72% of associations were statistically significant (p<0.05), only two showed convincing (class I) evidence: that between depressive disorders and all-cause mortality in patients with heart failure (hazard ratio, HR=1.44, 95% CI: 1.26-1.65), and that between schizophrenia and cardiovascular mortality in patients with cardiovascular diseases (risk ratio, RR=1.54, 95% CI: 1.36-1.75). Six associations showed highly suggestive (class II) evidence: those between depressive disorders and all-cause mortality in patients with diabetes mellitus (HR=2.84, 95% CI: 2.00-4.03) and with kidney failure (HR=1.41, 95% CI: 1.31-1.51); that between depressive disorders and major cardiac events in patients with myocardial infarction (odds ratio, OR=1.52, 95% CI: 1.36-1.70); that between depressive disorders and dementia in patients with diabetes mellitus (HR=2.11, 95% CI: 1.77-2.52); that between alcohol use disorder and decompensated liver cirrhosis in patients with hepatitis C (RR=3.15, 95% CI: 2.87-3.46); and that between schizophrenia and cancer mortality in patients with cancer (standardized mean ratio, SMR=1.74, 95% CI: 1.41-2.15). Sensitivity/subgroup analyses confirmed these results. The largest PAFs were 30.56% (95% CI: 27.67-33.49) for alcohol use disorder and decompensated liver cirrhosis in patients with hepatitis C, 26.81% (95% CI: 16.61-37.67) for depressive disorders and all-cause mortality in patients with diabetes mellitus, 13.68% (95% CI: 9.87-17.58) for depressive disorders and major cardiac events in patients with myocardial infarction, 11.99% (95% CI: 8.29-15.84) for schizophrenia and cardiovascular mortality in patients with cardiovascular diseases, and 11.59% (95% CI: 9.09-14.14) for depressive disorders and all-cause mortality in patients with kidney failure. The GIFs confirmed the preventive capacity of these associations. This umbrella review demonstrates that mental disorders increase the risk of a poor clinical outcome in several physical diseases. Prevention targeting mental disorders - particularly alcohol use disorders, depressive disorders, and schizophrenia - can reduce the incidence of adverse clinical outcomes in people with physical diseases. These findings can inform clinical practice and trans-speciality preventive approaches cutting across psychiatric and somatic medicine.

Distinguishing apathy from depression: A review differentiating the behavioral, neuroanatomic, and treatment-related aspects of apathy from depression in neurocognitive disorders

OBJECTIVES

This narrative review describes the clinical features of apathy and depression in individuals with neurocognitive disorders (NCDs), with the goal of differentiating the two syndromes on the basis of clinical presentation, diagnostic criteria, neuropathological features, and contrasting responses to treatments.

METHODS

Literature was identified using PubMed, with search terms to capture medical conditions of interest; additional references were also included based on our collective experience and knowledge of the literature.

RESULTS

Evidence from current literature supports the distinction between the two disorders; apathy and depression occur with varying prevalence in individuals with NCDs, pose different risks of progression to dementia, and have distinct, if overlapping, neurobiological underpinnings. Although apathy is a distinct neuropsychiatric syndrome, distinguishing apathy from depression can be challenging, as both conditions may occur concurrently and share several overlapping features. Apathy is associated with unfavorable outcomes, especially those with neurodegenerative etiologies (e.g., Alzheimer's disease) and is associated with an increased burden for both patients and caregivers. Diagnosing apathy is important not only to serve as the basis for appropriate treatment, but also for the development of novel targeted interventions for this condition. Although there are currently no approved pharmacologic treatments for apathy, the research described in this review supports apathy as a distinct neuropsychiatric condition that warrants specific treatments aimed at alleviating patient disability.

CONCLUSIONS

Despite differences between these disorders, both apathy and depression pose significant challenges to patients, their families, and caregivers; better diagnostics are needed to develop more tailored treatment and support.

Evaluating depression- and anxiety-like behaviors in non-human primates

Depression and anxiety are some of the most prevalent and debilitating mental health conditions in humans. They can present on their own or as co-morbidities with other disorders. Like humans, non-human primates (NHPs) can develop depression- and anxiety-like signs. Here, we first define human depression and anxiety, examine equivalent species-specific behaviors in NHPs, and consider models and current methods to identify and evaluate these behaviors. We also discuss knowledge gaps, as well as the importance of evaluating the co-occurrence of depression- and anxiety-like behaviors in animal models of human disease. Lastly, we consider ethical challenges in depression and anxiety research on NHPs in order to ultimately advance the understanding and the personalized treatment of these disorders.

Association of depression with cognitive frailty: A systematic review and meta-analysis

BACKGROUND AND AIM

The relationship between cognitive frailty and depression is unclear and quantitative analyses are lacking. We conducted a systematic review and meta-analysis to investigate the relationship between cognitive frailty and depression.

METHODS

We systematically searched Embase, PubMed, Medline (Ovid), Web of Science, and APA PsycInfo (American Psychological Association PsycInfo) databases until April 2022. Meta-analysis was performed using the Stata software. The prevalence between cognitive frailty and depression them was estimated by extracting the proportion of cognitive frailty and depression in the total number of patients. We extracted odds ratios (ORs) and 95 % confidence intervals (CI) to estimate the relationship between cognitive frailty and depression.

RESULTS

A meta-analysis of 15 studies revealed that cognitive frailty in older adults was associated with a higher risk of depression (OR = 2.06, 95 % CI = 1.72-2.48, p = 0.001). Eight studies involved the prevalence of cognitive frailty and depression, with an overall prevalence of depression of 46 % (95 % CI, 30 % -62 %; p < 0.0001) in cognitively frail patients.

LIMITATION

Differences in definitions and assessment methods for cognitive frailty across studies.

CONCLUSION

The prevalence of cognitive frailty combined with depression in the elderly is high wherein both are mutually affected. More prospective studies are needed to investigate the relationship between cognitive frailty and depression and to propose targeted treatment options and preventive measures to improve the quality of life of the elderly population.

Pharmacogenetics of anxiety and depression in Alzheimer's disease

Anxiety and depression coexist with cognitive impairment in Alzheimer's disease along with other concomitant disorders (>60%), which require multipurpose treatments. Polypharmaceutical regimens cause drug-drug interactions and adverse drug reactions, potentially avoidable in number and severity with the implementation of pharmacogenetic procedures. The accumulation of defective variants (>30 genes per patient in more than 50% of cases) in pharmagenes (pathogenic, mechanistic, metabolic, transporter, pleiotropic) influences the therapeutic response to antidementia, antidepressant and anxiolytic drugs in polyvalent regimens. APOE, CYP1A2, CYP2C9, CYP2C19, CYP2D6, CYP2E1, CYP3A4, CYP3A5, CYP4F2, COMT, MAOB, CHAT, GSTP1, NAT2, SLC30A8, SLCO1B1, ADRA2A, ADRB2, BCHE, GABRA1, HMGCR, HTR2C, IFNL3, NBEA, UGT1A1, ABCB1, ABCC2, ABCG2, SLC6A2, SLC6A3, SLC6A4, MTHFR and OPRM1 variants affect anxiety and depression in Alzheimer's disease.

Inter-relationship between cognitive performance and depressive symptoms and their association with quality of life in older adults: A network analysis based on the 2017-2018 wave of Chinese Longitudinal Healthy Longevity Survey (CLHLS)

BACKGROUND

Depressive symptoms and cognitive impairment are common psychiatric conditions and often co-occur in older adults. Network analysis has been widely used in exploring the inter-connections between psychiatric symptoms. The aim of this study was to explore the network model of depressive symptoms and cognitive performance, and their association with quality of life in people aged 65 years or above based on the 2017-2018 wave of Chinese Longitudinal Healthy Longevity Survey (CLHLS).

METHOD

Global cognitive performance, depressive symptoms, and global quality of life (QoL) were measured using the validated Chinese version of the Mini Mental State Examination (MMSE), the 10-item Center for Epidemiologic Studies Short Depression Scale (CES-D), and the World Health Organization Quality of Life-brief version (WHOQOL-BREF), respectively. Central symptoms and bridge symptoms were identified via strength and bridge strength, respectively. The flow network was used to identify symptoms directly related to QoL. Network stability was examined using the case dropping bootstrap method.

RESULTS

A total of 9023 participants were included in the network analysis. CESD3 "Feeling blue/depressed", CESD4 "Everything was an effort", and At_C "Attention and Calculation" were the central (influential) symptoms that had the highest strength value. Three bridge symptoms (i.e., Nam "Naming", CESD2 "Difficulty with concentrating", and Lan "Language") were also identified. CESD10 "Sleep disturbances" had the strongest direct connection to QoL.

CONCLUSIONS

This exploratory study highlights the inter-relationships between cognitive performance and depressive symptoms in older adults in the general population. Interventions targeting bridge symptoms have the potential to alleviate depressive and cognitive symptoms in this population. Furthermore, improving sleep quality in older adults may reduce the negative impact of depression and cognition decline on QoL.

Altered topological properties of functional brain networks in patients with first episode, late-life depression before and after antidepressant treatment

Objectives

To preliminarily explore the functional activity and information integration of the brains under resting state based on graph theory in patients with first-episode, late-life depression (LLD) before and after antidepressant treatment.

Methods

A total of 50 patients with first-episode LLD and 40 non-depressed controls (NCs) were recruited for the present research. Participants underwent the RBANS test, the 17-item Hamilton depression rating scale (HAMD-17) test, and resting-state functional MRI scans (rs-fMRI). The RBANS test consists of 12 sub-tests that contribute to a total score and index scores across the five domains: immediate memory, visuospatial/constructional, language, attention, and delayed memory. Escitalopram or sertraline was adopted for treating depression, and the dosage of the drug was adjusted by the experienced psychiatrists. Of the 50 LLD patients, 27 cases who completed 6-month follow-ups and 27 NCs matched with age, sex, and education level were included for the final statistical analysis.

Results

There were significant differences in RBANS total score, immediate memory, visuospatial/constructional, language, attention, and delayed memory between LLD baseline group and NCs group (P < 0.05). Considering the global attribute indicators, the clustering coefficient of global indicators was lower in the LLD baseline group than in the NCs group, and the small-world attribute of functional brain networks existed in all three groups. The degree centrality and node efficiency of some brains were lower in the LLD baseline group than in the NCs group. After 6 months of antidepressant therapy, the scores of HAMD-17, immediate memory, language, and delayed memory in the LLD follow-up group were higher than those in the LLD baseline group. Compared with the LLD baseline group, the degree centrality and node efficiency of some brains in the cognitive control network were decreased in the LLD follow-up group.

Conclusions

The ability to integrate and divide labor of functional brain networks declines in LLD patients and linked with the depression severity. After the relief of depressive symptoms, the small-world attribute of functional brain networks in LLD patients persists. However, the information transmission efficiency and centrality of some brain regions continue to decline over time, perhaps related to their progressive cognitive impairment.

Early Depressive Symptoms Predict Faster Dementia Progression in Autosomal-Dominant Alzheimer's Disease

BACKGROUND

Depression is associated with Alzheimer's disease (AD).

OBJECTIVE

To evaluate the association between depressive symptoms and age of onset of cognitive decline in autosomal dominant AD, and to determine possible factors associated to early depressive symptoms in this population.

METHODS

We conducted a retrospective study to identify depressive symptoms among 190 presenilin 1 (PSEN1) E280A mutation carriers, subjected to comprehensive clinical evaluations in up to a 20-year longitudinal follow-up. We controlled for the following potential confounders: APOE, sex, hypothyroidism, education, marital status, residence, tobacco, alcohol, and drug abuse.

RESULTS

PSEN1 E280A carriers with depressive symptoms before mild cognitive impairment (MCI) develop dementia faster than E280A carriers without depressive symptoms (Hazard Ratio, HR = 1.95; 95% CI, 1.15-3.31). Not having a stable partner accelerated the onset of MCI (HR = 1.60; 95 % CI, 1.03-2.47) and dementia (HR = 1.68; 95 % CI, 1.09-2.60). E280A carriers with controlled hypothyroidism had later age of onset of depressive symptoms (HR = 0.48; 95 % CI, 0.25-0.92), dementia (HR = 0.43; 95 % CI, 0.21-0.84), and death (HR = 0.35; 95 % CI, 0.13-0.95). APOEɛ2 significantly affected AD progression in all stages. APOE polymorphisms were not associate to depressive symptoms. Women had a higher frequency and developed earlier depressive symptoms than men throughout the illness (HR = 1.63; 95 % CI, 1.14-2.32).

CONCLUSION

Depressive symptoms accelerated progress and faster cognitive decline of autosomal dominant AD. Not having a stable partner and factors associated with early depressive symptoms (e.g., in females and individuals with untreated hypothyroidism), could impact prognosis, burden, and costs.

[Prognosis of late-life depression: clinical and immunological features]

OBJECTIVE

To study the outcomes of depression at a late age during a 3-year prospective follow-up in patients with various immunophenotypes.

MATERIAL AND METHODS

A cohort of patients with depressive disorders who were treated in a gerontopsychiatric hospital and re-examined after 1 and 3 years. The group with immunophenotype A (with increased activity of leukocyte elastase (LE) and complex depressions, comorbid with anxiety and senesto-hypochondriac disorders) included 20 people: 6 men (30%) and 14 women (70%), median age was 68 years. A depressive episode (DE) was diagnosed in 13 patients (65%) with recurrent depressive disorder (RDD) and in 7 patients (35%) with bipolar affective disorder (BAD). The group with immunophenotype B (with reduced activity of LE and prolonged apathetic-adynamic depression) included 31 people: 10 men (32.3%) and 21 women (67.7%), the median age was 68 years. DE was diagnosed in 20 patients (64.5%) with RDD, 9 patients (29%) with BAD, and in 2 patients (6.5%) with a single DE. The patients were examined using clinical, psychometric, immunological and clinical- follow-up methods (after 1 and 3 years).

RESULTS

More favorable course of the disease with the formation of high-quality remission was observed in patients with immunophenotype A (95% of cases after 1 and 3 years; χ2=10.44; p=0.001 and χ2=11.97; p=0.001, respectively). In patients with immunophenotype B, an unfavorable course of the disease prevailed (83.9 and 87.1% of cases after 1 and 3 years) with the formation of low-quality remissions (with residual depressive disorders, the development of repeated depressive phases and chronification of depression).

CONCLUSION

The study revealed the relationship between clinical and biological features and the course of late-life depression.

Common Neuropsychiatric S ymptoms in Alzheimer's Disease, Mild Cognitive Impairment, and Subjective Memory Complaints: A Unified Framework

The Alzheimer's disease (AD) continuum is a unique spectrum of cognitive impairment that typically involves the stages of subjective memory complaints (SMC), mild cognitive impairment (MCI), and AD dementia. Neuropsychiatric symptoms (NPS), such as apathy, anxiety, stress, and depression, are highly common throughout the AD continuum. However, there is a dearth of research on how these NPS vary across the AD continuum, especially SMC. There is also disagreement on the effects of specific NPS on each stage of the AD continuum due to their collinearity with other NPS, cognitive decline, and environmental factors (e.g., stress). In this article, we conduct a novel perspective review of the scientific literature to understand the presence of NPS across the AD continuum. Specifically, we review the effects of apathy, depression, anxiety, and stress in AD, MCI, and SMC. We then build on this knowledge by proposing two theories of NPS' occurrence across the AD continuum. Consequently, we highlight the current landscape, limitations (e.g., differing operationalization), and contentions surrounding the NPS literature. We also outline theories that could clear up contention and inspire future NPS research.

Effects of Mindful Awareness Practice (MAP) on Subclinical Depressive and Anxiety Symptoms and General Cognitive Function in Older Adults with Mild Cognitive Impairment: A 5-Year Follow-Up of the MAP-Randomized Controlled Trial

BACKGROUND

Few randomized controlled trials (RCTs) investigated the effects of mindfulness intervention on affective and cognitive symptoms in older adults with mild cognitive impairment (MCI). Furthermore, no RCTs on mindfulness followed participants beyond two years.

OBJECTIVE

To examine the longitudinal effects of a mindful awareness practice (MAP) intervention on depressive, anxiety, and cognitive symptoms in MCI.

METHODS

In this parallel-arm and assessor-blinded RCT, 55 community-dwelling older adults with MCI were randomized into the MAP or active control, i.e., health education program (HEP). Intervention sessions were conducted weekly for three months and monthly for the subsequent six months. Assessments and follow-up were conducted at baseline, 3-month, 9-month, and 5-year time points. Depressive, anxiety, and cognitive symptoms were measured using the Geriatric Depression Scale-15 (GDS-15), Geriatric Anxiety Inventory-20 (GAI-20), and Mini-Mental State Examination (MMSE), respectively. Linear-mixed models, following the intention-to-treat principle, were used for data analyses.

RESULTS

A total of 55 participants aged 60 to 86 (Mean age: 71.3±6 years old) was recruited, with n = 28 allocated to the MAP arm and n = 27 allocated to the HEP arm. Compared to HEP, GDS-15, GAI-20, and MMSE scores did not differ significantly in MAP during follow-ups.

CONCLUSION

Compared to HEP, MAP did not improve affective symptoms nor delay deteriorations in general cognition in community-dwelling older adults with MCI. Compared to our previous findings showing domain-specific improvements in MAP over HEP in attention and memory up to 9 months, this study highlights the importance of examining domain-specificity using detailed cognitive measures in non-pharmacological intervention with MCI.

Cognitive Impairment Mediates the Association between Dietary Inflammation and Depressive Symptoms in the Elderly

The underlying mechanism in both cognitive impairment and depression was chronic inflammation, which could be reflected by the dietary inflammatory index (DII). However, the effect of cognitive impairment on the association between DII and depression was not clear. Therefore, in this study, we hypothesized that cognitive impairment could mediate the association between dietary inflammation and depressive symptoms. A total of 2550 participants aged ≥60 from the National Health and Nutrition Examination Survey (NHANES) in 2011-2014 were involved in the serial, cross-sectional study. Proinflammatory and anti-inflammatory diets were measured by DII. Cognitive impairment was measured by four dimensions, CERAD-immediate, CERAN-delayed, animal fluency test, and DSST. Depressive symptoms were measured by PHQ-9 scores. We found that a proinflammatory diet and cognitive impairment were both risk factors for depressive symptoms. An interaction between an inflammatory diet and cognitive impairment was detected (P-interaction = 0.060). In addition, all four dimensions of cognition mediated the association between DII and depressive symptom scores. Part of the association between DII and depressive symptoms scores could be explained by different dimensions of cognitive function, and the proportion of mediation ranged from 10.0% to 36.7%. In conclusion, cognitive impairment levels partly mediated the association between DII and depressive symptoms.