Slowing Symptoms as Early Markers of Decline in Older Adults

The effectiveness of off-label dopamine stimulating agents in depressive disorder: A systematic review and meta-analysis

The chronicity of depressive disorders is a major problem. Dopamine stimulating agents (DSA) are suggested to hold a promising potential in depression management, particularly in older adults, in whom dopamine deficiency due to aging may be an underlying cause. More evidence is needed to support these drugs in the management of depression. Therefore, we conducted a systematic literature review and meta-analysis. Data was extracted from eighteen randomized-controlled-trials and eight open-label-studies. Additional meta-regression-analyses were performed to examine superiority of monotherapy versus augmentation, and to rule out a putative age effect. DSA were found to reduce depressive symptoms (SMD=-0.26, 95%CI[-0.43;-0.10]). Heterogeneity was high and a significant Egger's test indicated publication bias. Adjustment for missing studies, using trim-and-fill-methodology, reduced the effect size (SMD=-0.17, 95%CI[-0.39;0.05]), which lost statistical significance. Removing the outlier study from the analysis, the effect size remained marginally small, but was statistically-significant (SMD=-0.17, 95%CI[-0.31;-0.02]). Neither augmentation nor monotherapy was superior. No age effect was found. It can be concluded that off-label DSA are overall effective in reducing depressive symptoms. However, the evidence is weak, regarding the publication bias, and modest-to-weak treatment effects. Well-designed high-quality trials are highly needed, before dopamine stimulating agents can be adequately positioned in future depression treatment protocols.

Slowing: A Vascular Geriatric Syndrome?

OBJECTIVES

This study aimed to investigate the interrelation between slowing in walking, thinking and mood, and their relationship with cerebral small vessel disease (CSVD) in a geriatric population.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

566 geriatric outpatients from the Amsterdam Aging Cohort (49% female; age 79 ±6 years), who visited the Amsterdam UMC geriatric outpatient memory clinic.

METHODS

Patients underwent a comprehensive geriatric assessment, brain imaging, and a neuropsychological assessment as part of medical care. Three slowing aspects were investigated: gait speed, processing speed, and apathy symptoms (higher scores indicating more advanced slowing). We visually rated CSVD [white matter hyperintensities (WMHs), strategic lacunes, and microbleeds] on brain imaging.

RESULTS

Regression analyses showed that slowing in walking (gait speed) was associated with slowing in thinking [processing speed; β = 0.35, 95% confidence interval (CI) 0.22, 0.48] and slowing in mood (apathy symptoms; β = 0.21, 95% CI 0.13, 0.30), independent of important confounders. Large confluent areas of WMH (Fazekas 3) were associated with all slowing aspects: gait speed (β = 0.49, 95% CI 0.28, 0.71), processing speed (β = 0.36, 95% CI 0.19, 0.52) and apathy symptoms (β = 0.30, 95% CI 0.09, 0.51). In addition, in patients with more slowing aspects below predefined cutoffs, severe WMH was more common. Presence of ≥3 microbleeds was associated with apathy symptoms (β = 0.39, 95% CI 0.12, 0.66), whereas lacunes were not associated with slowing.

CONCLUSIONS AND IMPLICATIONS

This study provides evidence that slowing in walking, thinking, and mood are closely related and associated with CSVD. This phenotype or geriatric syndrome could be helpful to identify and characterize patients with CSVD.

Impaired Cognition Predicts Falls Among Women With and Without HIV Infection

OBJECTIVE

To determine whether domain-specific neurocognitive (NC) impairments predict falls in HIV+ compared with HIV- women.

DESIGN

Cross-sectional data analysis from 825 HIV+ and 392 HIV- women in the Women's Interagency HIV Study with NC testing within 2 years before falls surveys.

METHODS

NC impairment (T score <40) was assessed in 7 domains: executive function, psychomotor speed, attention, learning, memory, fluency, and fine motor function. For domains associated with any fall within 6 months in simple logistic regression (P < 0.05), hierarchical regression models evaluated associations between NC impairment and odds of falling, adjusting for: (1) study site and HIV, (2) demographics, (3) comorbid conditions, (4) substance use/central nervous system active medications, and HIV-specific factors.

RESULTS

Median age was higher in HIV+ than HIV- women (51 vs. 48 yrs); prevalence of falls was similar (19% HIV+, 16% HIV-). Overall, executive function [OR (odds ratio) = 1.82, 95% CI (confidence interval): 1.21 to 2.74; P = 0.004], psychomotor speed (OR = 1.59, 95% CI: 1.05 to 2.42, P = 0.03), and fine motor (OR 1.70, 95% CI: 1.11 to 2.61, P = 0.02) impairments were associated with greater odds of falls in fully adjusted models. In fully adjusted models, associations of executive function, psychomotor speed, and fine motor were nonsignificant among HIV+ women; conversely, among HIV- women, associations with impaired executive and fine motor functions were strengthened and remained significant.

CONCLUSIONS

Cognitive impairment was associated with falls among middle-aged HIV- but not HIV+ women. Additional studies should elucidate mechanisms by which domain-specific NC impairment impacts fall risk among older HIV+ and HIV- women and how different factors modify relationships between cognition and falls.