Cognitive Deficits in Older Adults With Psychotic Depression: A Meta-Analysis

Overview of late-onset psychoses

BACKGROUND

Several etiologies can underlie the development of late-onset psychosis, defined by first psychotic episode after age 40 years. Late-onset psychosis is distressing to patients and caregivers, often difficult to diagnose and treat effectively, and associated with increased morbidity and mortality.

METHODS

The literature was reviewed with searches in Pubmed, MEDLINE, and the Cochrane library. Search terms included "psychosis," "delusions," hallucinations," "late onset," "secondary psychoses," "schizophrenia," bipolar disorder," "psychotic depression," "delirium," "dementia," "Alzheimer's," "Lewy body," "Parkinson's, "vascular dementia," and "frontotemporal dementia." This overview covers the epidemiology, clinical features, neurobiology, and therapeutics of late-onset psychoses.

RESULTS

Late-onset schizophrenia, delusional disorder, and psychotic depression have unique clinical characteristics. The presentation of late-onset psychosis requires investigation for underlying etiologies of "secondary" psychosis, which include neurodegenerative, metabolic, infectious, inflammatory, nutritional, endocrine, and medication toxicity. In delirium, psychosis is common but controlled evidence is lacking to support psychotropic medication use. Delusions and hallucinations are common in Alzheimer's disease, and hallucinations are common in Parkinson's disease and Lewy body dementia. Psychosis in dementia is associated with increased agitation and a poor prognosis. Although commonly used, no medications are currently approved for treating psychosis in dementia patients in the USA and nonpharmacological interventions need consideration.

CONCLUSION

The plethora of possible causes of late-onset psychosis requires accurate diagnosis, estimation of prognosis, and cautious clinical management because older adults have greater susceptibility to the adverse effects of psychotropic medications, particularly antipsychotics. Research is warranted on developing and testing efficacious and safe treatments for late-onset psychotic disorders.

Cognitive performance among older adults with psychotic depression compared to non-psychotic depression

It remains unclear whether psychotic depression (PD) compared to non-psychotic depression (non-PD) among older adults is associated with poorer cognitive performance. For inpatients (60+) with a major depressive episode, cognitive performance in PD and non-PD (categorical) were compared as well as the relationship between symptom severity for depression and psychosis (dimensional) and cognition. Of 90 participants (on average 72.7 years old; range 60-92), 64% were female. The severity of depressive- and psychotic symptoms are both negatively associated with cognitive functioning among older adults with depression. This is of relevance for the treatment of this vulnerable group of patients.

The sirtuin family in health and disease

Sirtuins (SIRTs) are nicotine adenine dinucleotide(+)-dependent histone deacetylases regulating critical signaling pathways in prokaryotes and eukaryotes, and are involved in numerous biological processes. Currently, seven mammalian homologs of yeast Sir2 named SIRT1 to SIRT7 have been identified. Increasing evidence has suggested the vital roles of seven members of the SIRT family in health and disease conditions. Notably, this protein family plays a variety of important roles in cellular biology such as inflammation, metabolism, oxidative stress, and apoptosis, etc., thus, it is considered a potential therapeutic target for different kinds of pathologies including cancer, cardiovascular disease, respiratory disease, and other conditions. Moreover, identification of SIRT modulators and exploring the functions of these different modulators have prompted increased efforts to discover new small molecules, which can modify SIRT activity. Furthermore, several randomized controlled trials have indicated that different interventions might affect the expression of SIRT protein in human samples, and supplementation of SIRT modulators might have diverse impact on physiological function in different participants. In this review, we introduce the history and structure of the SIRT protein family, discuss the molecular mechanisms and biological functions of seven members of the SIRT protein family, elaborate on the regulatory roles of SIRTs in human disease, summarize SIRT inhibitors and activators, and review related clinical studies.

Towards an understanding of the pathological basis of senile depression and incident dementia: Implications for treatment

Senile depression (SD) is a heterogeneous syndrome. Several clinical profiles are more likely to appear in SD than in early-life depression, but it remains unclear whether the pathophysiology is different. The prevalence of dementia increases with aging, and the underlying pathophysiological processes in the preclinical phase begin even before cognitive deficits or neurological signs appear. SD may be either a risk factor for developing dementia or a prodromal stage of dementia. The inconsistent findings regarding the association between SD and incident dementia may be attributable to the neuropathological heterogeneity underlying SD. Most studies have focused on patients with the clinical diagnosis of Alzheimer disease (AD) as an outcome, but several clinicopathological studies suggest that primary age-related tauopathy and argyrophilic grain disease may account for a proportion of cases clinically misdiagnosed as AD in the elderly population. Furthermore, most AD cases have additional neuropathologic changes such as cerebrovascular disease and Lewy body disease. Here, we review the neuropathological findings linking SD to incident dementia, focusing on common age-related neuropathologies. In particular, the roles of disturbance of neural circuity, imbalance of monoaminergic systems, dysregulation of the hypothalamic-pituitary-adrenal axis, and elevated neuroinflammatory status are discussed. Finally, we review the current treatment of SD in the context of age-related neuropathological changes.

Abnormalities in visual cognition and associated impaired interactions between visual and attentional networks in schizophrenia and brief psychotic disorder

The extent and nature of cognitive impairment in brief psychotic disorder remains unclear, being rarely studied unlike schizophrenia. The present study hence sought to directly compare the visual cognitive dysfunction and its associated brain networks in brief psychotic disorder and schizophrenia. Data from picture completion (a complex visual task) and whole-brain functional connectome from resting-state fMRI were acquired from a sample of clinically stable patients with an established psychotic disorder (twenty with brief psychotic disorder, twenty with schizophrenia) and twenty-nine healthy controls. Group differences and the inter-relationships in task performances and brain networks were tested. Picture completion task deficits were found in brief psychotic disorder compared with healthy controls, though the deficits were less than schizophrenia. Task performance also correlated with severity of psychotic symptoms in patients. The task performance was inversely correlated with the functional connectivity between peripheral visual and attentional networks (dorsal attention and salience ventral attention), with increased functional connectivity in brief psychotic disorder compared with healthy controls and in schizophrenia compared with brief psychotic disorder. Present findings showed pronounced visual cognitive impairments in brief psychotic disorder that were worse in schizophrenia, underpinned by abnormal interactions between higher-order attentional and lower-order visual processing networks.

Depressive symptoms increase the risk of falls and injurious falls in Chinese adults aged ≥ 45 years: A 3-year cohort study

Background

Falls and depressive symptoms are both public health concerns in China, but the effects of depressive symptoms on falls and injurious falls have not been thoroughly investigated.

Methods

This population-based prospective cohort study used data derived from adults aged ≥45 years acquired from the 2015 and 2018 China Health and Retirement Longitudinal Study. Data were analyzed from August 2021 to December 2021. Self-reported depressive symptoms were determined using a 10-item Center for Epidemiologic Studies Depression scale (CESD-10) with a total score range of 0-30. Item responses of 3-4 or 5-7 days were deemed indicative of specific depressive symptoms. The outcome variables were self-reported accidental falls and injurious falls.

Results

Of the 12,392 participants included in the study, 3,671 (29.6%) had high baseline depressive symptoms (CESD-10 scores ≥ 10), 1,892 (15.3%) experienced falls, and 805 (6.5%) experienced injurious falls during 2015-2018 follow-up. High depressive symptoms increased the risk of falls [odds ratio (OR) 1.34, 95% confidence interval (CI) 1.19-1.50] and injurious falls (OR 1.28, 95% CI 1.09-1.51) in a multivariable logistic regression model adjusted for major demographic, health-related, and anthropometric covariates. All of the 10 specific depressive symptoms except "felt hopeless" were associated with falls, and four specific symptoms significantly increased the risk of injurious falls; "had trouble concentrating" (OR 1.32, 95% CI 1.13-1.55); "felt depressed" (OR 1.32, 95% CI 1.12-1.55); "everything was an effort" (OR 1.23, 95% CI 1.04-1.45); and "restless sleep" (OR 1.18, 95% CI 1.02-1.40).

Conclusion

High depressive symptoms are significantly related to risk of falls and injurious falls. Four specific symptoms (had trouble concentrating, felt depressed, everything was an effort, and restless sleep) increase the risk of injurious falls in Chinese adults aged ≥ 45 years.

Validation and Comparison of Three Short Depression Screening Tools Among Chinese Community-Dwelling Older Adults

The current study validated and compared three short Geriatric Depression Scales (GDS), including the GDS-5, D'Ath GDS-4, and van Marwijk GDS-4, among 917 Chinese community-dwelling older adults. The GDS-5, D'Ath GDS-4, and van Marwijk GDS-4 presented satisfactory accuracy against the GDS-15 (area under the curve [AUC] = 0.872 to 0.952), and the GDS-5 and D'Ath GDS-4 had better accuracy than the van Marwijk GDS-4. Satisfactory accuracy (AUC = 0.842 to 0.979) for the three scales was also observed across subgroups by age, sex, education, cognitive function, and multimorbidity. The GDS-5 but not D'Ath GDS-4 and van Marwijk GDS-4 retained a 2-point optimal cutoff for depressive symptoms across subgroups. The GDS-5 (average inter-item correlation coefficient [AIIC] = 0.233) and the D'Ath GDS-4 (AIIC = 0.171) but not van Marwijk GDS-4 (AIIC = 0.128) had acceptable internal consistency. Three scales had stable test-retest reliability within a 1- to 2-week interval (intraclass correlation coefficient = 0.670 to 0.885). The GDS-5 is an accurate and reliable depression screening tool with an invariable optimal cutoff among Chinese community-dwelling older adults. The variable optimal cutoffs for the D'Ath GDS-4 and van Marwijk GDS-4 across subgroups may limit their applicability in this population. [Research in Gerontological Nursing, xx(x), xx-xx.].

Prevalence of Comorbid Dementia in Late-life Depression and Bipolar Disorder: A Retrospective Inpatient Study

Background:

Dementia in patients with late-life mood disorders is clinically important.

Objective:

We aimed to investigate the prevalence of dementia in patients with late-life major depressive disorder (MDD) or bipolar disorder (BD) and to clarify the clinical characteristics associated with the diagnosis of dementia.

Methods:

The prevalence of dementia at hospital discharge and the clinical characteristics at hospitalization who are diagnosed with MDD or BD over 65 years of age, from the medical records of 684 patients who had been admitted from 2015 to 2020 were investigated.

Results:

A total of 66 patients with MDD (n = 50) and BD (n = 16) were analyzed. The prevalence of dementia was significantly higher in MDD than in BD (24.0% versus 0%; p = 0.026). The mean age at onset of MDD was significantly older in the MDD with dementia group than in the MDD without (76.9±6.3 years versus 62.2±14.0 years; p < 0.001). The rate of first depressive episode at this admission was significantly higher in the MDD with dementia group (91.7% versus 30.3%; p < 0.001). The diagnosis of dementia was significantly associated with lower scores for “insomnia early” (p = 0.019) and higher scores for “insight” (p = 0.049) on the 17-item Hamilton Depression Rating (HAMD-17) subscales and lower scores for “recall” (p = 0.003) on the MMSE subscales.

Conclusion:

The older age of first onset of depression, “insomnia early”, “insight” and “recall” may be useful indicators for a diagnosis of dementia in late-life depression.

Identification of Hub Genes Related to Alzheimer's Disease and Major Depressive Disorder

BackgroundAlthough many studies reported a close relationship between depression and Alzheimer's disease (AD), the underlying pathophysiological mechanism remains unclear. The present study aimed to investigate the mechanism of AD and major depressive disorder (MDD). Method: The datasets were downloaded from the Gene Expression Omnibus. After screening differentially expressed genes (DEGs), gene ontology and pathway analysis were performed and protein-protein interaction, TF-target gene, and miRNA-target gene networks were established. Results: 171 DEGs of AD-related datasets and 79 DEGs shared by AD and MDD were detected. Functional analysis revealed that AD and MDD common genes were significantly enriched in circadian entrainment and long-term depression signaling pathways. Five hub genes were identified after construction of networks and validation of hub gene signatures. In conclusion, DYNC1H1, MAPRE3, TTBK2, ITGB1, and WASL may be potential targets for the diagnosis and treatment of AD and MDD.

Psychotic depression in hospitalized patients: Longitudinal outcomes of psychotic vs. nonpsychotic depression among inpatients

Even though psychotic depression is related to worse outcomes than nonpsychotic depression, there is increasing evidence that this greater severity is not solely explained by the depressive symptoms. We evaluated the socio-demographic and clinical characteristics, as well as the differences in clinical outcomes of psychiatric hospitalization between psychotic and non-psychotic depression. Two-hundred-eighty-eight depressive inpatients were assessed within 72 h after hospitalization and 24 h before discharge. We compared scores of Hamilton Depression Rating Scale 17-items (HDRS-17), Clinical Global Impression (CGI), Brief Psychiatric Rating Scale (BPRS), and Global Assessment of Functioning (GAF) between psychotic and nonpsychotic patients. Instruments were compared both cross-sectionally - on admission and discharge - and longitudinally. Longitudinal outcomes were corrected for potential confounders (sex, age, age at disease onset, years of study, previous history of mania/hypomania, electroconvulsive therapy in current hospitalization, history of attempted suicide, number of suicide attempts, and previous hospitalizations). One-hundred-thirty-one depressive inpatients (45.4%) presented psychotic features. Both groups showed similar HDRS-17 scores at admission and discharge. However, psychotic patients had worse scores on BPRS, CGI, and GAF at both timepoints. Both groups had similar improvement on HDRS-17 (P = 0.75), CGI (P = 0.5), and GAF (P = 0.84), but psychotic patients had greater improvement on BPRS (P < 0.001). Psychotic inpatients showed worse clinical and functional parameters. Nonetheless, the groups did not differ in depressive symptom severity. These findings reinforce the hypothesis that depressive episode with psychotic features is a more severe form of the disease irrespective of intensity of affective symptomatology.

Shared genetic etiology underlying Alzheimer's disease and major depressive disorder

Patients with late-onset Alzheimer's disease (LOAD) frequently manifest comorbid neuropsychiatric symptoms with depression and anxiety being most frequent, and individuals with major depressive disorder (MDD) have an increased prevalence of LOAD. This suggests shared etiologies and intersecting pathways between LOAD and MDD. We performed pleiotropy analyses using LOAD and MDD GWAS data sets from the International Genomics of Alzheimer's Project (IGAP) and the Psychiatric Genomics Consortium (PGC), respectively. We found a moderate enrichment for SNPs associated with LOAD across increasingly stringent levels of significance with the MDD GWAS association (LOAD|MDD), of maximum four and eightfolds, including and excluding the APOE-region, respectively. Association analysis excluding the APOE-region identified numerous SNPs corresponding to 40 genes, 9 of which are known LOAD-risk loci primarily in chromosome 11 regions that contain the SPI1 gene and MS4A genes cluster, and others were novel pleiotropic risk-loci for LOAD conditional with MDD. The most significant associated SNPs on chromosome 11 overlapped with eQTLs found in whole-blood and monocytes, suggesting functional roles in gene regulation. The reverse conditional association analysis (MDD|LOAD) showed a moderate level, ~sevenfold, of polygenic overlap, however, no SNP showed significant association. Pathway analyses replicated previously reported LOAD biological pathways related to immune response and regulation of endocytosis. In conclusion, we provide insights into the overlapping genetic signatures underpinning the common phenotypic manifestations and inter-relationship between LOAD and MDD. This knowledge is crucial to the development of actionable targets for novel therapies to treat depression preceding dementia, in an effort to delay or ultimately prevent the onset of LOAD.