Vascular burden and cognitive function in late-life depression

The enigma of vascular depression in old age: a critical update

Depression is common in older individuals and is associated with high disability and increased mortality, yet the factors predicting late-life depression (LLD) are poorly understood. The relationship between of depressive disorder, age- and disease-related processes have generated pathogenic hypotheses and provided new treatment options. LLD syndrome is often related to a variety of vascular mechanisms, in particular hypertension, cerebral small vessel disease, white matter lesions, subcortical vascular impairment, and other processes (e.g., inflammation, neuroimmune regulatory dysmechanisms, neurodegenerative changes, amyloid accumulation) that may represent etiological factors by affecting frontolimbic and other neuronal networks predisposing to depression. The "vascular depression" hypothesis suggests that cerebrovascular disease (CVD) and vascular risk factors may predispose, induce or perpetuate geriatric depressive disorders. It is based on the presence of various cerebrovascular risk factors in many patients with LLD, its co-morbidity with cerebrovascular lesions, and the frequent development of depression after stroke. Other findings related to vascular depression are atrophy of the medial temporal cortex or generalized cortical atrophy that are usually associated with cognitive impairment. Other pathogenetic hypotheses of LLD, such as metabolic or inflammatory ones, are briefly discussed. Treatment planning should consider there may be a modest response to antidepressants, but several evidence-based and novel treatment options for LLD exist, such as electroconvulsive therapy, transcranial magnetic stimulation, neurobiology-based psychotherapy, as well as antihypertension and antiinflammatory drugs. However, their effectiveness needs further investigation, and new methodologies for prevention and treatment of depression in older individuals should be developed.

Comparing cardiovascular risk factors in older persons with mild cognitive impairment and lifetime history of major depressive disorder

OBJECTIVES

To compare the prevalence of select cardiovascular risk factors (CVRFs) in patients with mild cognitive impairment (MCI) versus lifetime history of major depression disorder (MDD) and a normal comparison group using baseline data from the Prevention of Alzheimer's Dementia with Cognitive Remediation plus Transcranial Direct Current Stimulation (PACt-MD) study.

DESIGN

Baseline data from a multi-centered intervention study of older adults with MCI, history of MDD, or combined MCI and history of MDD (PACt-MD) were analyzed.

SETTING

Community-based multi-centered study based in Toronto across 5 academic sites.

PARTICIPANTS

Older adults with MCI, history of MDD, or combined MCI and history of MDD and healthy controls.

MEASUREMENTS

We examined the baseline distribution of smoking, hypertension and diabetes in three groups of participants aged 60+ years in the PACt-MD cohort study: MCI (n = 278), MDD (n = 95), and healthy older controls (n = 81). Generalized linear models were fitted to study the effect of CVRFs on MCI and MDD as well as neuropsychological composite scores.

RESULTS

A higher odds of hypertension among the MCI cohort compared to healthy controls (p < .05) was noted in unadjusted analysis. Statistical significance level was lost on adjusting for age, sex and education (p > .05). A history of hypertension was associated with lower performance in composite executive function (p < .05) and overall composite neuropsychological test score (p < .05) among a pooled cohort with MCI or MDD.

CONCLUSIONS

This study reinforces the importance of treating modifiable CVRFs, specifically hypertension, as a means of mitigating cognitive decline in patients with at-risk cognitive conditions.

Pathomechanisms of Vascular Depression in Older Adults

Depression in older individuals is a common complex mood disorder with high comorbidity of both psychiatric and physical diseases, associated with high disability, cognitive decline, and increased mortality The factors predicting the risk of late-life depression (LLD) are incompletely understood. The reciprocal relationship of depressive disorder and age- and disease-related processes has generated pathogenic hypotheses and provided various treatment options. The heterogeneity of depression complicates research into the underlying pathogenic cascade, and factors involved in LLD considerably differ from those involved in early life depression. Evidence suggests that a variety of vascular mechanisms, in particular cerebral small vessel disease, generalized microvascular, and endothelial dysfunction, as well as metabolic risk factors, including diabetes, and inflammation that may induce subcortical white and gray matter lesions by compromising fronto-limbic and other important neuronal networks, may contribute to the development of LLD. The "vascular depression" hypothesis postulates that cerebrovascular disease or vascular risk factors can predispose, precipitate, and perpetuate geriatric depression syndromes, based on their comorbidity with cerebrovascular lesions and the frequent development of depression after stroke. Vascular burden is associated with cognitive deficits and a specific form of LLD, vascular depression, which is marked by decreased white matter integrity, executive dysfunction, functional disability, and poorer response to antidepressive therapy than major depressive disorder without vascular risk factors. Other pathogenic factors of LLD, such as neurodegeneration or neuroimmune regulatory dysmechanisms, are briefly discussed. Treatment planning should consider a modest response of LLD to antidepressants, while vascular and metabolic factors may provide promising targets for its successful prevention and treatment. However, their effectiveness needs further investigation, and intervention studies are needed to assess which interventions are appropriate and effective in clinical practice.

Vascular Depression and Cognition in Mexican Americans

BACKGROUND

Mexican Americans are at increased risk of developing mild cognitive impairment (MCI) and Alzheimer's disease compared to non-Hispanic whites. This study sought to examine the relationship between vascular risk, depression, and cognition in Mexican American elders.

METHODS

Data from 470 (390 normal controls, 80 MCI patients) Mexican Americans enrolled in the Health and Aging Brain among Latino Elders (HABLE) study were used. The cardiovascular risk was assessed by the Framingham Risk Score. Cognition was assessed with a neuropsychological battery, and depression was assessed based on scores from the Geriatric Depression Scale (GDS). ANOVAs were utilized to determine the differences in neuropsychological scores of normal controls with and without depression and CVD risk (low vs. high). Follow-up logistic regression was conducted to determine MCI risk.

RESULTS

The results of this study indicated that comorbid depression and a high CVD risk were associated with poorer cognitive performance in Mexican Americans. Depressed women with high CVD risk were more likely to have executive dysfunction, language deficits, and poorer global cognition than nondepressed women with a high CVD risk. In Mexican American men, those with a high vascular risk and depression were more likely to have executive dysfunction and poorer immediate memory than the nondepressed high-risk group. Higher GDS scores (OR = 1.10; 95% CI 1.02-1.10, p = 0.001) and higher vascular risk scores (OR = 1.05; 95% CI 1.02-1.10, p = 0.001) significantly predicted MCI status in Mexican Americans.

CONCLUSION

The results of this study indicated that comorbid depression and a high CVD risk were associated with poorer cognitive performance and increased risk of MCI in Mexican Americans.

Cardiovascular diseases and related risk factors accelerated cognitive deterioration in patients with late-life depression: a one-year prospective study

OBJECTIVES

Cognitive impairment in late-life depression is common and associated with a higher risk of all-cause dementia. Late-life depression patients with comorbid cardiovascular diseases (CVDs) or related risk factors may experience higher risks of cognitive deterioration in the short term. We aim to investigate the effect of CVDs and their related risk factors on the cognitive function of patients with late-life depression.

METHODS

A total of 148 participants were recruited (67 individuals with late-life depression and 81 normal controls). The presence of hypertension, coronary heart disease, diabetes mellitus, or hyperlipidemia was defined as the presence of comorbid CVDs or related risk factors. Global cognitive functions were assessed at baseline and after a one-year follow-up by the Mini-Mental State Examination (MMSE). Global cognitive deterioration was defined by the reliable change index (RCI) of the MMSE.

RESULTS

Late-life depression patients with CVDs or related risk factors were associated with 6.8 times higher risk of global cognitive deterioration than those without any of these comorbidities at a one-year follow-up. This result remained robust after adjusting for age, gender, and changes in the Hamilton Depression Rating Scale (HAMD) scores.

CONCLUSIONS

This study suggests that late-life depression patients with comorbid CVDs or their related risk factors showed a higher risk of cognitive deterioration in the short-term (one-year follow up). Given that CVDs and their related risk factors are currently modifiable, active treatment of these comorbidities may delay rapid cognitive deterioration in patients with late-life depression.

Study design of the Routine Outcome Monitoring for Geriatric Psychiatry & Science (ROM-GPS) project; a cohort study of older patients with affective disorders referred for specialised geriatric mental health care

BACKGROUND

Affective disorders, encompassing depressive-, anxiety-, and somatic symptom disorders, are the most prevalent mental disorders in later life. Treatment protocols and guidelines largely rely on evidence from RCTs conducted in younger age samples and ignore comorbidity between these disorders. Moreover, studies in geriatric psychiatry are often limited to the "younger old" and rarely include the most frail. Therefore, the effectiveness of treatment in routine clinical care for older patients and impact of ageing characteristics is largely unknown.

OBJECTIVE

The primary aim of the Routine Outcome Monitoring for Geriatric Psychiatry & Science (ROM-GPS) - project is to examine the impact of ageing characteristics on the effectiveness of treatment for affective disorders in specialised geriatric mental health care.

METHODS

ROM-GPS is a two-stage, multicentre project. In stage one, all patients aged ≥60 years referred to participating outpatient clinics for specialised geriatric mental health care will be routinely screened with a semi-structured psychiatric interview, the Mini International Neuropsychiatric Interview and self-report symptom severity scales assessing depression, generalized anxiety, hypochondria, and alcohol use. Patients with a unipolar depressive, anxiety or somatic symptom disorder will be asked informed consent to participate in a second (research) stage to be extensively phenotyped at baseline and closely monitored during their first year of treatment with remission at one-year follow-up as the primary outcome parameter. In addition to a large test battery of potential confounders, specific attention is paid to cognitive functioning (including computerized tests with the Cogstate test battery as well as paper and pencil tests) and physical functioning (including multimorbidity, polypharmacy, and different frailty indicators). The study is designed as an ongoing project, enabling minor adaptations once a year (change of instruments).

DISCUSSION

Although effectiveness studies using observational data can easily be biased, potential selection bias can be quantified and potentially corrected (e.g. by propensity scoring). Knowledge of age-related determinants of treatment effectiveness, may stimulate the development of new interventions. Moreover, studying late-life depressive, anxiety and somatic symptom disorders jointly enables data-driven studies for more optimal classification of these disorders in later life.

TRIAL REGISTRATION

Dutch Trial Register: NL6704 ( www.trialregister.nl ). Retrospectively registered on 2017-12-05.

Vascular depression consensus report - a critical update

BACKGROUND

Vascular depression is regarded as a subtype of late-life depression characterized by a distinct clinical presentation and an association with cerebrovascular damage. Although the term is commonly used in research settings, widely accepted diagnostic criteria are lacking and vascular depression is absent from formal psychiatric manuals such as the Diagnostic and Statistical Manual of Mental Disorders, 5^th edition - a fact that limits its use in clinical settings. Magnetic resonance imaging (MRI) techniques, showing a variety of cerebrovascular lesions, including extensive white matter hyperintensities, subcortical microvascular lesions, lacunes, and microinfarcts, in patients with late life depression, led to the introduction of the term "MRI-defined vascular depression".

DISCUSSION

This diagnosis, based on clinical and MRI findings, suggests that vascular lesions lead to depression by disruption of frontal-subcortical-limbic networks involved in mood regulation. However, despite multiple MRI approaches to shed light on the spatiotemporal structural changes associated with late life depression, the causal relationship between brain changes, related lesions, and late life depression remains controversial. While postmortem studies of elderly persons who died from suicide revealed lacunes, small vessel, and Alzheimer-related pathologies, recent autopsy data challenged the role of these lesions in the pathogenesis of vascular depression. Current data propose that the vascular depression connotation should be reserved for depressed older patients with vascular pathology and evident cerebral involvement. Based on current knowledge, the correlations between intra vitam neuroimaging findings and their postmortem validity as well as the role of peripheral markers of vascular disease in late life depression are discussed.

CONCLUSION

The multifold pathogenesis of vascular depression as a possible subtype of late life depression needs further elucidation. There is a need for correlative clinical, intra vitam structural and functional MRI as well as postmortem MRI and neuropathological studies in order to confirm the relationship between clinical symptomatology and changes in specific brain regions related to depression. To elucidate the causal relationship between regional vascular brain changes and vascular depression, animal models could be helpful. Current treatment options include a combination of vasoactive drugs and antidepressants, but the outcomes are still unsatisfying.

Cognitive performance in depressed older persons: the impact of vascular burden and remission. A two-year follow-up study

OBJECTIVES

Depression is associated with an increased risk of cognitive decline. The present study compared two-year change in cognitive performance between depressed older persons and a non-depressed control group, between remitted and non-remitted patients, and evaluated whether vascular burden at baseline was associated with more cognitive decline in depressed older persons.

METHODS

Depressed patients (n = 378) aged ≥60 were recruited from mental healthcare institutes and general practices, and a non-depressed control group (n = 132) was recruited from general practices. A DSM-IV depressive episode was established with the Composite International Diagnostic Interview, and processing speed, working memory, verbal memory and interference control were evaluated with three neurocognitive tasks at baseline and 2 years later. A modified Framingham Risk Score, ankle-brachial index, and history of a vascular event defined vascular burden at baseline.

RESULTS

After adjusting for baseline cognitive performance, age, sex, and education level, depressed older persons had worse processing speed and verbal memory scores at follow-up than controls (regression coefficients: -0.172; p = 0.042 and -0.309; p = 0.001, respectively) but did not differ in the other two-cognitive outcomes. In the sample of depressed patients, remission status at 2 years follow-up and baseline vascular burden did not predict cognitive performance at follow-up, after adjustment for baseline cognitive performance, age, sex and education level.

CONCLUSIONS

Our findings suggest that cognitive deficits in depressed older persons are not just a manifestation of depression. In addition, vascular burden was not associated with worse cognitive decline in a sample of depressed older persons. Copyright © 2016 John Wiley & Sons, Ltd.

Cardiovascular risk assessment in patients with a severe mental illness: a systematic review and meta-analysis

BACKGROUND

Cardiovascular risk (CVR) has been observed to be higher in patients with severe mental illness (SMI) than in the general population. However, some studies suggest that CVR is not equally increased in different subgroups of SMI. The purposes of this review are to summarise CVR scores of SMI patients and to determine the differences in CVR between patients with different SMIs and between SMI patients and the control-population.

METHODS

MEDLINE (via PubMed) was searched for literature published through August 28, 2014, followed by a snowball search in the Web of Science. Observational and experimental studies that reported CVR assessments in SMI patients using validated tools were included. The risk of bias was reported using STROBE and CONSORT criteria. Pooled continuous data were expressed as standardized mean differences (SMD) with 95% confidence intervals (CI). Two reviewers independently selected studies, extracted data and assessed methodological quality.

RESULTS

A total of 3,608 articles were identified, of which 67 full text papers were assessed for eligibility and 35 were finally included in our review, in which 12,179 psychiatric patients and 225,951 comparative patients had been assessed. The most frequent diagnoses were schizophrenia and related diagnoses (45.7%), depressive disorders (14.7%), SMI (11.4%) and bipolar disorders (8.6%). The most frequent CVR assessment tool used was the Framingham risk score. Subgroups analysis showed a higher CVR in schizophrenia than in depressive disorder or in studies that included patients with multiple psychiatric diagnoses (SMD: 0.63, 0.03, and 0.02, respectively). Six studies were included in the meta-analysis. Total overall CVR did not differ between SMI patients and controls (SMD: 0.35 [95% CI:-0.02 to 0.71], p = 0.06); high heterogeneity was observed (I (2) = 93%; p < 0.001).

CONCLUSIONS

The summary of results from studies that assessed CVR using validated tools in SMI patients did not find sufficient data (except for limited evidence associated with schizophrenia) to permit any clear conclusions about increased CVR in this group of patients compared to the general population. The systematic review is registered in

PROSPERO

CRD42013003898 .