A longitudinal study of differences in late- and early-onset geriatric depression: depressive symptoms and psychosocial, cognitive, and neurological functioning

Cognitive improvement in late-life depression treated with vortioxetine and duloxetine in an eight-week randomized controlled trial: The role of age at first onset and change in depressive symptoms

BACKGROUND

Age at first onset of depression as a clinical factor affecting cognitive improvement in late life depression was investigated.

METHODS

This is a secondary analysis of an eight-week randomized controlled trial involving 452 elderly patients treated by vortioxetine, duloxetine or placebo (1:1:1). Patients were subcategorized into early-onset (LLD-EO) and late-onset (LLD-LO) groups divided by onset age of 50. Cognitive performance was assessed by composite score of Digit Symbol Substitution Test (DSST) and the Rey Auditory Verbal Learning Test (RAVLT) tasks, while depressive symptoms were assessed by Montgomery-Åsberg Depression Rating Scale (MADRS).

RESULTS

Vortioxetine and duloxetine exhibited advantages versus placebo in improving cognitive performance in the LLD-LO group, yet not in the LLD-EO group after eight weeks. Patients in the LLD-EO group showed overall advantage to placebo in depressive symptoms before endpoint (week 8) of treatment, while patients in the LLO-LO group showed no advantage until endpoint. Path analysis suggested a direct effect of vortioxetine (B = 0.656, p = .036) and duloxetine (B = 0.726, p = .028) on improving cognition in the LLD-LO group, yet in all-patients treated set both medications improved cognition indirectly through changes of depressive symptoms.

LIMITATION

Reliability of clinical history could raise caution as it was collected by subjective recall of patients.

CONCLUSION

Age at first onset might affect cognitive improvement as well as change in depressive symptoms and its mediation towards cognitive improvement in late life depression treated with vortioxetine and duloxetine.

Prospective exploration of the role of combined internalizing symptoms in self-reported memory among older adults during the COVID-19 pandemic

OBJECTIVES

A growing literature suggests depression and anxiety increase risk of cognitive decline. However, few studies have examined their combined effects on cognition, among older adults, especially during periods of high stress.

METHOD

Based on a sample of community dwelling older adults (N = 576), we evaluated the effects of pre-pandemic anxiety and depressive symptoms, obtained in September 2018, to changes in self-reported memory (SRM) assessed 3 months into the COVID-19 pandemic.

RESULTS

In separate models, we found participants with depression scores at least 1-SD above the mean and participants with anxiety scores at least 2-SD above the mean to report a significant decline in SRM. Moderation analyses revealed those with high depressive symptoms (at or above the mean) showed a decrease in SRM regardless of anxiety. The extent to which high pre-pandemic anxiety symptoms influenced SRM is dependent on whether pre-pandemic depression was at or above the mean.

CONCLUSIONS

Pre-pandemic depression predicted a decline in SRM regardless of anxiety. Moderation analyses revealed that the extent to which anxiety symptoms influenced SRM was dependent on depression being at or above the mean. Those with high anxiety and depression are at highest risk of experiencing cognitive consequences related to stressful exposures like COVID-19.

Cluster analysis dissecting cognitive deficits in older adults with major depressive disorder and the association with neurofilament light chain

BACKGROUND

Cognitive impairment is a growing problem with increasing burden in global aging. Older adults with major depressive disorder (MDD) have higher risk of dementia. Neurofilament light chain (NfL) has been proven as a potential biomarker in neurodegenerative disease, including dementia. We aimed to investigate the association between cognitive deficits and NfL levels in older adults with MDD.

METHODS

In this cross-sectional study, we enrolled 39 MDD patients and 15 individuals with mild neurocognitive disorder or major neurocognitive disorder, Alzheimer's type, as controls, from a tertiary psychiatric hospital. Both groups were over age 65 and with matched Mini-Mental State Examination (MMSE) score. Demographic data, clinical variables, and plasma NfL levels were obtained. We used cluster analysis according to their cognitive profile and estimated the correlation between plasma NfL levels and each cognitive domain.

RESULTS

In the MDD group, participants had higher rate of family psychiatry history and current alcohol use habit compared with controls. Control group of neurocognitive disorders showed significantly lower score in total MMSE and higher plasma NfL levels. Part of the MDD patients presented cognitive deficits clustered with that of neurocognitive disorders (cluster A). In cluster A, the total MMSE score (r=-0.58277, p=0.0287) and the comprehension domain (r=-0.71717, p=0.0039) were negatively correlated to NfL levels after adjusting for age, while the associations had not been observed in the other cluster.

CONCLUSIONS

We noted the negative correlation between NfL levels and cognition in MDD patients clustered with neurodegenerative disorder, Alzheimer's type. NfL could be a promising candidate as a biomarker to predict subtype of patients in MDD to develop cognitive decline. Further longitudinal studies and within MDD cluster analysis are required to validate our findings for clinical implications.

Regional gray matter volume correlates with anxiety, apathy, and resilience in geriatric depression

OBJECTIVES

Geriatric depression (GD) is associated with significant medical comorbidity, cognitive impairment, brain atrophy, premature mortality, and suboptimal treatment response. While apathy and anxiety are common comorbidities, resilience is a protective factor. Understanding the relationships between brain morphometry, depression, and resilience in GD could inform clinical treatment. Only few studies have addressed gray matter volume (GMV) associations with mood and resilience.

PARTICIPANTS

Forty-nine adults aged >60 years (38 women) with major depressive disorder undergoing concurrent antidepressant treatment participated in the study.

MEASUREMENTS

Anatomical T1-weighted scans, apathy, anxiety, and resilience data were collected. Freesurfer 6.0 was used to preprocess T1-weighted images and qdec to perform voxel-wise whole-brain analyses. Partial Spearman correlations controlling for age and sex tested the associations between clinical scores, and general linear models identified clusters of associations between GMV and clinical scores, with age and sex as covariates. Cluster correction and Monte-Carlo simulations were applied (corrected alpha = 0.05).

RESULTS

Greater depression severity was associated with greater anxiety (r = 0.53, p = 0.0001), lower resilience (r = -0.33, p = 0.03), and greater apathy (r = 0.39, p = 0.01). Greater GMV in widespread, partially overlapping clusters across the brain was associated with reduced anxiety and apathy, as well as increased resilience.

CONCLUSION

Our results suggest that greater GMV in extended brain regions is a potential marker for resilience in GD, while GMV in more focal and overlapping regions may be markers for depression and anxiety. Interventions focused on improving symptoms in GD may seek to examine their effects on these brain regions.

Brain-cognition relationships in late-life depression: a systematic review of structural magnetic resonance imaging studies

BACKGROUND

Most patients with late-life depression (LLD) have cognitive impairment, and at least one-third meet diagnostic criteria for mild cognitive impairment (MCI), a prodrome to Alzheimer's dementia (AD) and other neurodegenerative diseases. However, the mechanisms linking LLD and MCI, and brain alterations underlying impaired cognition in LLD and LLD + MCI remain poorly understood.

METHODS

To address this knowledge gap, we conducted a systematic review of studies of brain-cognition relationships in LLD or LLD + MCI to identify circuits underlying impaired cognition in LLD or LLD + MCI. We searched MEDLINE, PsycINFO, EMBASE, and Web of Science databases from inception through February 13, 2023. We included studies that assessed cognition in patients with LLD or LLD + MCI and acquired: (1) T1-weighted imaging (T1) measuring gray matter volumes or thickness; or (2) diffusion-weighted imaging (DWI) assessing white matter integrity. Due to the heterogeneity in studies, we only conducted a descriptive synthesis.

RESULTS

Our search identified 51 articles, resulting in 33 T1 studies, 17 DWI studies, and 1 study analyzing both T1 and DWI. Despite limitations, reviewed studies suggest that lower thickness or volume in the frontal and temporal regions and widespread lower white matter integrity are associated with impaired cognition in LLD. Lower white matter integrity in the posterior cingulate region (precuneus and corpus callosum sub-regions) was more associated with impairment executive function and processing speed than with memory.

CONCLUSION

Future studies should analyze larger samples of participants with various degrees of cognitive impairment and go beyond univariate statistical models to assess reliable brain-cognition relationships in LLD.

Linking individual variability in functional brain connectivity to polygenic risk in major depressive disorder

BACKGROUND

Major depressive disorder (MDD) is a highly heterogeneous disease, which brings great difficulties to clinical diagnosis and therapy. Its mechanism is still unknown. Prior neuroimaging studies mainly focused on mean differences between patients and healthy controls (HC), largely ignoring individual differences between patients.

METHODS

This study included 112 MDD patients and 93 HC subjects. Resting-state functional MRI data were obtained to examine the patterns of individual variability of brain functional connectivity (IVFC). The genetic risk of pathways including dopamine, 5-hydroxytryptamine (5-HT), norepinephrine (NE), hypothalamic-pituitary-adrenal (HPA) axis, and synaptic plasticity was assessed by multilocus genetic profile scores (MGPS), respectively.

RESULTS

The IVFC pattern of the MDD group was similar but higher than that in HCs. The inter-network functional connectivity in the default mode network contributed to altered IVFC in MDD. 5-HT, NE, and HPA pathway genes affected IVFC in MDD patients. The age of onset, duration, severity, and treatment response, were correlated with IVFC. IVFC in the left ventromedial prefrontal cortex had a mediating effect between MGPS of the 5-HT pathway and baseline depression severity.

LIMITATIONS

Environmental factors and differences in locations of functional areas across individuals were not taken into account.

CONCLUSIONS

This study found MDD patients had significantly different inter-individual functional connectivity variations than healthy people, and genetic risk might affect clinical manifestations through brain function heterogeneity.

Biological factors influencing depression in later life: role of aging processes and treatment implications

Late-life depression occurring in older adults is common, recurrent, and malignant. It is characterized by affective symptoms, but also cognitive decline, medical comorbidity, and physical disability. This behavioral and cognitive presentation results from altered function of discrete functional brain networks and circuits. A wide range of factors across the lifespan contributes to fragility and vulnerability of those networks to dysfunction. In many cases, these factors occur earlier in life and contribute to adolescent or earlier adulthood depressive episodes, where the onset was related to adverse childhood events, maladaptive personality traits, reproductive events, or other factors. Other individuals exhibit a later-life onset characterized by medical comorbidity, pro-inflammatory processes, cerebrovascular disease, or developing neurodegenerative processes. These later-life processes may not only lead to vulnerability to the affective symptoms, but also contribute to the comorbid cognitive and physical symptoms. Importantly, repeated depressive episodes themselves may accelerate the aging process by shifting allostatic processes to dysfunctional states and increasing allostatic load through the hypothalamic-pituitary-adrenal axis and inflammatory processes. Over time, this may accelerate the path of biological aging, leading to greater brain atrophy, cognitive decline, and the development of physical decline and frailty. It is unclear whether successful treatment of depression and avoidance of recurrent episodes would shift biological aging processes back towards a more normative trajectory. However, current antidepressant treatments exhibit good efficacy for older adults, including pharmacotherapy, neuromodulation, and psychotherapy, with recent work in these areas providing new guidance on optimal treatment approaches. Moreover, there is a host of nonpharmacological treatment approaches being examined that take advantage of resiliency factors and decrease vulnerability to depression. Thus, while late-life depression is a recurrent yet highly heterogeneous disorder, better phenotypic characterization provides opportunities to better utilize a range of nonspecific and targeted interventions that can promote recovery, resilience, and maintenance of remission.

Sex differences in residual somatic symptoms in patients with first-episode depression after acute-phase treatment

BACKGROUND

Residual somatic symptoms (RSS) are common in depressed patients, predicting treatment effectiveness. However, sex differences in RSS have received little systematic study. This study was conducted to compare sex differences of RSS in patients with first-episode depression (FED).

METHODS

Nine hundred eighty-two patients with FED were selected and treated for 8 to 12 weeks. We evaluated the subjects' socio-demographic characteristics and residual depressive symptoms. Using the Patient Health Questionnaire-15 (PHQ-15) scale to assess residual somatic symptoms, the Sheehan Disability Scale (SDS) for the assessment of patients' function, the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF) for quality of life.

RESULTS

The incidence of RSS with FED was 46.4%. For patients with residual symptoms, the age and age of onset in females were higher than males, but males had more years of education than females. The degree of "stomach pain" in females was more severe than in males, while "trouble sleeping" in males was more severe than that in females. Multiple regression analysis showed that the total Q-LES-Q-SF score was an independent influencing factor of RSS in both males and females, while the total SDS score only affected female RSS.

CONCLUSIONS

The prevalence of RSS in FED after acute-phase treatment is high. The symptom of "stomachache" is more pronounced in females, while "trouble sleeping" is more severe in males. Quality of life plays an essential role in RSS in both genders. Thus, sex needs to be considered when assessing the relationship between RSS and therapeutic effect in depression.

Trajectories analysis of comorbid depression and anxiety among Israeli veterans: The implications on cognitive performance

BACKGROUND

Among war veterans, research has indicated high rates of depression, anxiety, and comorbidity of these disorders, with even higher rates among prisoners-of-war. However, little is known about the longitudinal effects of comorbidity profiles on cognitive performance, particularly in the case of aging war veterans.

METHOD

This longitudinal study focuses on Israeli veterans from the 1973 Yom Kippur War, with assessments at four time-points: 1991 (T1), 2003 (T2), 2008 (T3), and 2015 (T4). Two groups were included: veterans who were held captive (ex-POWs; n = 196), and veterans who were not (war veterans; n = 159). Participants completed validated self-report measures, and their cognitive performance was assessed using the Montreal Cognitive Assessment (MoCA).

RESULTS

Three distinct profiles of comorbidity were identified: resiliency (57.5%, n = 204); delayed-onset (29.6%, n = 105), and chronic (13.00%, n = 46). The chronic profile identified mostly among ex-POW (91.3%, n = 42), veterans with lower education at T1, and with more cognitively impaired compared to the other profiles (p < .0001). No differences were found between the profiles in age and family status at T1.

CONCLUSIONS

The findings highlight the importance of viewing aging veterans as a high-risk population for cognitive impairments, particularly those suffering from chronic comorbidity of depression and anxiety. Therefore, the appropriate diagnosis and cognitive treatment are required to preserve cognitive abilities and prevent decline.

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.

Associations of depression and regional brain structure across the adult lifespan: Pooled analyses of six population-based and two clinical cohort studies in the European Lifebrain consortium

OBJECTIVE

Major depressive disorder has been associated with lower prefrontal thickness and hippocampal volume, but it is unknown whether this association also holds for depressive symptoms in the general population. We investigated associations of depressive symptoms and depression status with brain structures across population-based and patient-control cohorts, and explored whether these associations are similar over the lifespan and across sexes.

METHODS

We included 3,447 participants aged 18-89 years from six population-based and two clinical patient-control cohorts of the European Lifebrain consortium. Cross-sectional meta-analyses using individual person data were performed for associations of depressive symptoms and depression status with FreeSurfer-derived thickness of bilateral rostral anterior cingulate cortex (rACC) and medial orbitofrontal cortex (mOFC), and hippocampal and total grey matter volume (GMV), separately for population-based and clinical cohorts.

RESULTS

Across patient-control cohorts, depressive symptoms and presence of mild-to-severe depression were associated with lower mOFC thickness (r_symptoms = -0.15/ r_status = -0.22), rACC thickness (r_symptoms = -0.20/ r_status = -0.25), hippocampal volume (r_symptoms = -0.13/ r_status = 0.13) and total GMV (r_symptoms = -0.21/ r_status = -0.25). Effect sizes were slightly larger for presence of moderate-to-severe depression. Associations were similar across age groups and sex. Across population-based cohorts, no associations between depression and brain structures were observed.

CONCLUSIONS

Fitting with previous meta-analyses, depressive symptoms and depression status were associated with lower mOFC, rACC thickness, and hippocampal and total grey matter volume in clinical patient-control cohorts, although effect sizes were small. The absence of consistent associations in population-based cohorts with mostly mild depressive symptoms, suggests that significantly lower thickness and volume of the studied brain structures are only detectable in clinical populations with more severe depressive symptoms.

Coordinate-Based Network Mapping of Brain Structure in Major Depressive Disorder in Younger and Older Adults: A Systematic Review and Meta-Analysis

OBJECTIVE

Structural neuroimaging findings in younger and older adults with major depressive disorder (MDD) are highly heterogeneous, possibly as a result of methodological limitations, lack of distinction between MDD and late-life depression (LLD), or clinical moderators. Using a novel meta-analytic network mapping approach, the authors sought to identify the circuits affected in different clinical subtypes of MDD.

METHODS

The authors identified all voxel-based and surface-based morphometry studies published through October 2020 that compared younger adults with MDD or older adults with LLD to nonpsychiatric control participants. An activation likelihood estimation (ALE) analysis and a novel coordinate-based network mapping approach were used to identify brain circuits affected in MDD and LLD. Meta-regressions examined the impact of age at onset in older patients with LLD and treatment with antidepressants in younger patients with MDD.

RESULTS

The authors analyzed 145 comparisons from 143 articles, including a total of 14,318 participants (MDD: N=6,362; LLD: N=535; control subjects: N=7,421). Significant ALE results confirmed previous findings implicating the left and right parahippocampus and anterior cingulate in MDD and the anterior cingulate in LLD. In contrast, coordinate-based network mapping showed differences in the frontoparietal, dorsal attention, and visual networks both in MDD and LLD. Meta-regressions showed that late onset was significantly associated with widespread structural abnormalities in LLD, and treatment with antidepressants showed a significant association with abnormalities in the anterior cingulate (Brodmann's area 32) and dorsolateral prefrontal cortex (Brodmann's area 9) in MDD.

CONCLUSIONS

These findings help to clarify the shared circuitry of depression across the adult lifespan and highlight some unique circuitry relevant to late-onset depression, which may explain some of the risk for cognitive decline and dementia.

Deep learning-based automated speech detection as a marker of social functioning in late-life depression

BACKGROUND

Late-life depression (LLD) is associated with poor social functioning. However, previous research uses bias-prone self-report scales to measure social functioning and a more objective measure is lacking. We tested a novel wearable device to measure speech that participants encounter as an indicator of social interaction.

METHODS

Twenty nine participants with LLD and 29 age-matched controls wore a wrist-worn device continuously for seven days, which recorded their acoustic environment. Acoustic data were automatically analysed using deep learning models that had been developed and validated on an independent speech dataset. Total speech activity and the proportion of speech produced by the device wearer were both detected whilst maintaining participants' privacy. Participants underwent a neuropsychological test battery and clinical and self-report scales to measure severity of depression, general and social functioning.

RESULTS

Compared to controls, participants with LLD showed poorer self-reported social and general functioning. Total speech activity was much lower for participants with LLD than controls, with no overlap between groups. The proportion of speech produced by the participants was smaller for LLD than controls. In LLD, both speech measures correlated with attention and psychomotor speed performance but not with depression severity or self-reported social functioning.

CONCLUSIONS

Using this device, LLD was associated with lower levels of speech than controls and speech activity was related to psychomotor retardation. We have demonstrated that speech activity measured by wearable technology differentiated LLD from controls with high precision and, in this study, provided an objective measure of an aspect of real-world social functioning in LLD.

Geriatric Depression and Cognitive Impairment-An Update

BACKGROUND

Depression and cognitive impairment often coexist in older adults. The relation between depression and cognitive impairment is complex. The objective of this article is to review recent literature on cognitive impairment in older adults with depression and provide clinicians an update.

METHODS

We searched PubMed, Google Scholar, Science Direct, and Psych Info for the articles published in the English language related to late-life depression (LLD)/geriatric depression and cognitive impairment. We considered original research articles, relevant systematic reviews, chapters, and important conceptual articles published in the last 9 years (2011-2019). We selected relevant articles for this narrative review.

CONCLUSION

The concept pseudodementia, indicating depression with cognitive impairment mimicking dementia, is now seen only as a historical concept. The current literature strongly agrees with fact that cognitive deficits often exist in LLD. The cognitive deficits in depression were initially seen as trait marker; however, some recent studies suggest that cognitive deficits persist even in the remission phase. There is heterogeneity among the studies in terms of the nature of the cognitive deficits, but higher number of studies reported impairment in attention and executive function. LLD with cognitive deficits is at a higher risk of progression to dementia. In older adults, depression with cognitive impairments requires a comprehensive evaluation. Electroencephalography, event-related potentials, fluorodeoxyglucose-positron emission tomography, amyloid positron emission tomography, and CSF amyloid will supplement clinical evaluation in differentiating functional depressive disorder with cognitive impairment from depression with an underlying degenerative condition.

Identification of specific neural circuit underlying the key cognitive deficit of remitted late-onset depression: A multi-modal MRI and machine learning study

Neuropsychological impairment is a key feature of late-onset depression (LOD), with deficits observed across multiple cognitive domains. And this neuropsychological impairment can persist even after the remission of depressive symptoms. However, none of previous studies have explored the pattern of cognitive deficit in remitted LOD (rLOD), and investigated the specific neural circuit underlying the key cognitive deficit of LOD. 40 rLOD patients and 36 controls underwent comprehensive neuropsychological assessments and magnetic resonance imaging (MRI) scans. The influence of executive function or information processing speed deficit on other cognitive domains was first investigated. We then applied a multivariate machine learning technique known as relevance vector regression to evaluate the potential of multiple-modal MRI (i.e., integrating whole-brain grey-matter [GM] volume and white-matter [WM] tract features) for making accurate predictions about the key cognitive deficit for individual rLOD patient. We revealed that the information processing speed appears to represent a key cognitive deficit in rLOD. Further the machine learning model identified a wide range of GM regions and WM tracts that significantly contributed to the prediction of individual performance on information processing speed (r = 0.50, P < 0.001). The GM regions mainly located in the frontal-subcortical and limbic systems; and the WM tracts mainly located in the frontal-limbic pathway, including the anterior corona radiata, fornix, posterior cingulate bundle, and uncinate fasciculus. This present study provide strongly evidence supporting the concept of rLOD that the core aspect of the cognitive deficits (i.e., information processing speed) is associated with disruption of the frontal-subcortical-limbic pathway.

Psychological training to improve psychosocial function in patients with major depressive disorder: A randomised clinical trial

Cognitive and emotional remediation training for depression (CERT-D): a randomised controlled trial to improve cognitive, emotional and functional outcomes in depression The aim of the current study was to evaluate an experimental treatment designed to improve psychosocial function in patients with Major Depressive Disorder (MDD) by reinforcing cognitive, emotional, and social-cognitive abilities. Participants (N = 112) with current or lifetime MDD were recruited to participate in a randomised, blinded, controlled trial. Exclusion criteria included diagnosis of a substance abuse disorder, bipolar disorder organic, eating disorders, or illness which affect cognitive function. The treatment involved repeated cognitive training designed to improve cognitive, emotional, and social-cognitive abilities. In training sessions, the principles of cognitive training were applied across cognitive, emotional, and social domains, with participants completing repeated mental exercises. Exercises included critically analysing interpretations of social interactions (e.g., body language), exploring emotional reactions to stimuli, and completing game-like cognitive training tasks. Training sessions placed great emphasis on the application of trained cognitive, emotional, and social cognitive skills to psychosocial outcomes. Outcomes demonstrated significant improvement in psychosocial function, symptom severity, self-reported cognition, and social-cognition. Our findings demonstrate the efficacy of multi-domain cognitive training to improve psychosocial functioning in individuals with MDD. We suggest that the present treatment could be deployed at a lower cost and with minimal training in comparison to established psychological therapies.

Relationship between childhood physical abuse and clinical severity of treatment-resistant depression in a geriatric population

Introduction

We assessed the correlation between childhood maltreatment (CM) and severity of depression in an elderly unipolar Treatment-Resistant Depression (TRD) sample.

Methods

Patients were enrolled from a longitudinal cohort (FACE-DR) of the French Network of Expert TRD Centres.

Results

Our sample included 96 patients (33% of the overall cohort) aged 60 years or above, with a mean age of 67.2 (SD = 5.7). The majority of the patients were female (62.5%). The Montgomery and Asberg Depression Rating Scale (MADRS) and Quick Inventory Depression Scale-Self Report (QIDS-SR) mean scores were high, 28.2 (SD = 7.49) [MADRS score range: 0–60; moderate severity≥20, high severity≥35] and 16.5 (SD = 4.94) [IDS-SR score range: 0–27; moderate severity≥11, high severity≥16], respectively. Mean self-esteem scores were 22.47 (SD = 6.26) [range 0–30]. In an age- and sex-adjusted model, we found a positive correlation between childhood trauma (CTQ scores) and depressive symptom severity [MADRS (β = 0.274; p = 0.07) and QIDS-SR (β = 0.302; p = 0.005) scores]. We detected a statistically significant correlation between physical abuse and depressive symptom severity [MADRS (β = 0.304; p = 0.03) and QIDS-SR (β = 0.362; p = 0.005) scores]. We did not observe any significant correlation between other types of trauma and depressive symptom severity. We showed that self-esteem (Rosenberg scale) mediated the effect of physical abuse (PA) on the intensity of depressive symptoms [MADRS: b = 0.318, 95% BCa C.I. [0.07, 0.62]; QIDS-SR: b = 0.177, 95% BCa C.I. [0.04, 0.37]]. Preacher & Kelly’s Kappa Squared values of 19.1% (k² = 0.191) and 16% (k² = 0.16), respectively for the two scales, indicate a moderate effect.

Conclusion

To our knowledge, this is the first study conducted in a geriatric TRD population documenting an association between childhood trauma (mainly relating to PA) and the intensity of depressive symptoms.

Gender differences and long-term outcome of over 75 elderlies in cardiac rehabilitation: highlighting the role of psychological and physical factors through a secondary analysis of a cohort study

BACKGROUND

Despite cardiac rehabilitation for elder people already showed its usefulness, to date it is still not clear the impact of gender and of psychological constructs in influencing the rehabilitation outcomes.

AIM

This study aimed at exploring the gender differences of great elders (over 75 years old) in cardiac rehabilitation, with particular attention to the impact of physical and psychological conditions, as depressive symptoms, on long-term post-discharge outcomes.

DESIGN

A cohort study design was used and a secondary analysis was conducted.

SETTING

Cardiac rehabilitation unit of a postacute rehabilitation Institute.

POPULATION

Elderly patients over 75 years old admitted to the cardiac rehabilitation program.

METHODS

Psychological and functional variables, such as Barthel Index, BMI, quality of life, and depression measured at admission and discharge from CR were matched with mortality information up to 4 years, used as long-term outcomes.

RESULTS

A total of 523 patients, 228 females and 295 males, with a mean age of 76.27 years±3.46 were progressively enrolled. Barthel index at admission and discharge was higher for males than females, 74.10±17.31 vs. 68.90 SD±16.81 (P<0.001), and 95.45±10.64 vs. 92.95±13.03 (p=0.021), respectively, while the relative change from admission to discharge Δ% of Barthel was higher for females 0.25±0.18 than for males 0.21±0.17 (P<0.05). Compared to males, either at admission or discharge females presented more severe depressive symptoms (5.21±3.46 vs. 3.86±2.79, P<0.001; 4.15±3.21 vs. 2.93±2.45, P<0.001) and a worse quality of life (10.58±2.15 vs. 9.55±2.24, P<0.001; 7.5±1.63 vs. 7.02±1.08, P=0.018). Cox proportional analysis revealed that female gender, depression at discharge, Barthel, and Comorbidity Index were associated with higher hazard and shorter survival time. On the other hand, higher BMI was associated with lower hazard and longer survival time.

CONCLUSIONS

Elderly women following a CR program present more disability, depression, and a worse QoL than men. Obviously, these characteristics influence the length of hospitalization but with significant improvement. Despite the frail-gender paradox regarding survival, after CR program women have a higher risk of mortality than men. Depression has a significant negative impact on elderly psychophysical health.

CLINICAL REHABILITATION IMPACT

Gender-specific and individualized rehabilitation programs should be implemented by considering the discussed physical and psychological risk factors. Further insight about gender differences among over 75 elderlies in CR is provided, this knowledge may be useful for clinicians scheduling recovery plans to promote elderlies' psychological and physical health. Psychological interventions should be implemented to relieve the depressive symptoms among elders.

Trajectories of depressive symptoms and associated patterns of cognitive decline

The aim was to investigate the pattern and rate of cognitive decline across distinctive trajectories of depressive symptoms in older adults. In this prospective multinational cohort study on 69,066 participants (on average 64 years at baseline, 55% women), assessments of cognitive functions (immediate recall, delayed recall, verbal fluency) and depressive symptoms (EURO-D scale) were conducted at 2-year intervals. The trajectories of depressive symptoms were obtained using latent growth mixture modelling, cognitive decline was assessed using smoothing splines and linear mixed effects models. Four distinct trajectories of depressive symptoms were identified: constantly low (n = 49,660), constantly high (n = 2999), increasing (n = 6828) and decreasing (n = 9579). Individuals with increasing and constantly high depressive symptoms showed linear cognitive decline, while those with constantly low and decreasing depressive symptoms had fluctuating cognition. Participants with increasing depressive symptoms had the fastest decline, while those with decreasing symptoms were spared from decline in cognition. This study suggests that the pattern as well as the rate of cognitive decline co-occurs with specific patterns of changes in depressive symptoms over time. The most pronounced cognitive decline is present in individuals, in whom depressive symptoms increase late in life. Unique mechanisms of cognitive decline may exist for subgroups of the population, and are associated with the trajectory of depressive symptoms.

The Effect of Cognitive Impairment on the Prognosis of Major Depressive Disorder

The study recruited 168 patients diagnosed with major depressive disorder (MDD). The nine-item Patient Health Questionnaire (PHQ-9) and Perceived Deficits Questionnaire for Depression (PDQ-D) were lower and the Digit Symbol Substitution Test (DSST) was higher in the community volunteers than those in MDD patients. Depression-related scores (17-item Hamilton Depression Rating Scale [HAMD-17], Clinical Global Impressions-Severity of Illness Scale [CGI-S], and PHQ-9), functioning-related scores (Sheehan Disability Scale [SDS]), and Work Efficiency and Activity Damage-Specific Health Problems questionnaire work productivity loss were decreased, and the quality of life-related scores (European Quality of life-5 Dimensions [EQ-5D] utility score) were increased in the MDD patients. PDQ-D was decreased and DSST was increased with the increase of follow-up time. Linear regression indicated that cognitive symptoms (PDQ-D and DSST) improved more slowly than depressive symptoms (PHQ-9). At baseline, PDQ-D was related with functioning (SDS and work productivity loss). PDQ-D and DSST were related with EQ-5D utility score. In addition, at month 6, PDQ-D was related with functioning (SDS and work productivity loss) and EQ-5D utility score. Cognitive impairment might be a risk for MDD and MDD-related changes in the functioning and quality of life.

Constructing classification boundaries in the memory clinic: negotiating risk and uncertainty in constituting mild cognitive impairment

Determining the boundaries around processes of 'normal' ageing and pathological cognitive deterioration associated with Alzheimer's disease (AD) is a difficult process, complicated further by the expansion of the disease category to include mild cognitive impairment (MCI). MCI is a label used to identify individuals with the symptoms of cognitive deterioration not attributable to 'normal ageing' but deemed to be 'at risk' of developing AD despite clinical uncertainty around whether individuals will go on to develop the condition in the future. Drawing on qualitative data gathered across an out-patient memory service, this article examines practitioners' accounts of the complexity associated with constructing the boundaries around MCI, AD and age in the clinic. Practitioners utilise uncertainty by classifying patients with MCI to keep them on for review to account for the possibility that patients may go on to develop AD but they also recognise the difficulty in predicting future progression to AD. Negotiating classification boundaries in the clinic is, however, not only about managing uncertainty regarding potential future risk but also about navigating the wider social and political context in which ageing and cognitive deterioration intersect, and are constructed and managed.

Frontal-executive and corticolimbic structural brain circuitry in older people with remitted depression, mild cognitive impairment, Alzheimer's dementia, and normal cognition

A history of depression is a risk factor for dementia. Despite strong epidemiologic evidence, the pathways linking depression and dementia remain unclear. We assessed structural brain alterations in white and gray matter of frontal-executive and corticolimbic circuitries in five groups of older adults putatively at-risk for developing dementia- remitted depression (MDD), non-amnestic MCI (naMCI), MDD+naMCI, amnestic MCI (aMCI), and MDD+aMCI. We also examined two other groups: non-psychiatric ("healthy") controls (HC) and individuals with Alzheimer's dementia (AD). Magnetic resonance imaging (MRI) data were acquired on the same 3T scanner. Following quality control in these seven groups, from diffusion-weighted imaging (n = 300), we compared white matter fractional anisotropy (FA), mean diffusivity (MD), and from T1-weighted imaging (n = 333), subcortical volumes and cortical thickness in frontal-executive and corticolimbic regions of interest (ROIs). We also used exploratory graph theory analysis to compare topological properties of structural covariance networks and hub regions. We found main effects for diagnostic group in FA, MD, subcortical volume, and cortical thickness. These differences were largely due to greater deficits in the AD group and to a lesser extent aMCI compared with other groups. Graph theory analysis revealed differences in several global measures among several groups. Older individuals with remitted MDD and naMCI did not have the same white or gray matter changes in the frontal-executive and corticolimbic circuitries as those with aMCI or AD, suggesting distinct neural mechanisms in these disorders. Structural covariance global metrics suggested a potential difference in brain reserve among groups.

Evidence for Structural and Functional Alterations of Frontal-Executive and Corticolimbic Circuits in Late-Life Depression and Relationship to Mild Cognitive Impairment and Dementia: A Systematic Review

Depression is a risk factor for developing Alzheimer's disease and Related Dementia (ADRD). We conducted a systematic review between 2008 and October 2018, to evaluate the evidence for a conceptual mechanistic model linking depression and ADRD, focusing on frontal-executive and corticolimbic circuits. We focused on two neuroimaging modalities: diffusion-weighted imaging measuring white matter tract disruptions and resting-state functional MRI measuring alterations in network dynamics in late-life depression (LLD), mild cognitive impairment (MCI), and LLD+MCI vs. healthy control (HC) individuals. Our data synthesis revealed that in some but not all studies, impairment of both frontal-executive and corticolimbic circuits, as well as impairment of global brain topology was present in LLD, MCI, and LLD+MCI vs. HC groups. Further, posterior midline regions (posterior cingulate cortex and precuneus) appeared to have the most structural and functional alterations in all patient groups. Future cohort and longitudinal studies are required to address the heterogeneity of findings, and to clarify which subgroups of people with LLD are at highest risk for developing MCI and ADRD.

Late life depressive symptoms and cognitive function among older Mexican adults: the past and the present

Objective: To evaluate associations between depression and individual cognitive domains and how changes in depressive symptoms relate to cognition three years later in the context of Mexico, a developing country experiencing rapid aging.Method: Data comes from the 2012 and 2015 waves of the Mexican Health and Aging Study (n = 12,898, age 50+). Depression is ascertained using a modified Center for Epidemiologic Studies - Depression Scale. Cognition is assessed using verbal learning, verbal memory, visual scanning, verbal fluency, visuospatial ability, visual memory, and orientation tasks. Depressive symptoms and cognitive functioning were both measured in 2012 and 2015. Scores across cognitive domains are modeled using ordinary least squares regression, adjusting for demographic, health, and economic covariates.Results: When depression and cognition were measured concurrently in 2015, depression exhibited associations with all cognitive domains. When considering a respondent's history of depression, individuals who had elevated depressive symptoms in 2012 and recovered by 2015 continued to exhibit poorer cognitive function in 2015 in verbal learning, verbal memory, visual scanning, and verbal fluency tasks compared to individuals who were neither depressed in 2012 nor 2015.Conclusions: Depression was associated with cognition across cognitive domains among older Mexican adults. Despite improvements in depressive symptomatology, formerly depressed respondents continued to perform worse than their counterparts without a history of depression on several cognitive tasks. In addition to current mental health status, researchers should consider an individual's history of depression when assessing the cognitive functioning of older adults.

Depressive disorders in the elderly and dementia: An update

The relationship between depressive disorders in the elderly and dementia, particularly Alzheimer’s disease (AD), is highly complex. While the nature of this relationship is still a matter of debate, differential diagnosis and treatment remain a great clinical challenge. We review recent findings on the conundrum of depressive disorders in the elderly and AD. There is a biological continuum between depressive disorders in the elderly – or at least a subgroup of them – and AD. While elderly subjects with depression and patients with AD exhibit higher circulating levels of pro-inflammatory molecules and lower BDNF than matched controls, CSF levels of Aβ42 can discriminate AD from depressive disorders in the elderly. The role of antidepressant treatment as a strategy to minimize the risk of AD remains to be established.

Electroconvulsive therapy response in late-life depression unaffected by age-related brain changes

BACKGROUND

Gray matter volume decrease, white matter vascular pathology and amyloid accumulation are age-related brain changes that have been related to the pathogenesis of late life depression (LLD). Furthermore, lower hippocampal volume and more white matter hyperintensities (WMH) may contribute to poor response to electroconvulsive therapy (ECT) in severely depressed older adults. We hypothesized that the accumulation of age-related brain changes negatively affects outcome following ECT in LLD.

METHODS

34 elderly patients with severe LLD were treated twice weekly with ECT until remission. All had both 3T structural magnetic resonance imaging (MRI) and β-amyloid positron emission tomography (PET) imaging using 18F-flutemetamol at baseline. MADRS and MMSE were obtained weekly which included 1 week prior to ECT (T0), after the sixth ECT (T1), and one week (T2) after the last ECT as well as at four weeks (T3) and 6 months (T4) after the last ECT. We conducted a multiple logistic regression analysis and a survival analysis with neuroimaging measures as predictors, and response, remission and relapse as outcome variable.

RESULTS

We did not find any association between baseline hippocampal volume, white matter hyperintensity volume and total amyloid load and response or remission at 1 and 4 weeks post ECT, nor with relapse at week 4.

LIMITATIONS

The present exploratory study was conducted at a single center academic hospital, the sample size was small, the focus was on hippocampal volume and the predictive effect of structural and molecular changes associated with aging were used.

CONCLUSIONS

Our study shows no evidence of relationship between response to ECT and age-related structural or molecular brain changes, implying that ECT can be applied effectively in depressed patients irrespective of accumulating age-related brain changes.

The power of sample size through a multi-scanner approach in MR neuroimaging regression analysis: evidence from Alzheimer's disease with and without depression

The inconsistency of volumetric results often seen in MR neuroimaging studies can be partially attributed to small sample sizes and variable data analysis approaches. Increased sample size through multi-scanner studies can tackle the former, but combining data across different scanner platforms and field-strengths may introduce a variability factor capable of masking subtle statistical differences. To investigate the sample size effect on regression analysis between depressive symptoms and grey matter volume (GMV) loss in Alzheimer's disease (AD), a retrospective multi-scanner investigation was conducted. A cohort of 172 AD patients, with or without comorbid depressive symptoms, was studied. Patients were scanned with different imaging protocols in four different MRI scanners operating at either 1.5 T or 3.0 T. Acquired data were uniformly analyzed using the computational anatomy toolbox (CAT12) of the statistical parametric mapping (SPM12) software. Single- and multi-scanner regression analyses were applied to identify the anatomical pattern of correlation between GM loss and depression severity. A common anatomical pattern of correlation between GMV loss and increased depression severity, mostly involving sensorimotor areas, was identified in all patient subgroups imaged in different scanners. Analysis of the pooled multi-scanner data confirmed the above finding employing a more conservative statistical criterion. In the retrospective multi-scanner setting, a significant correlation was also exhibited for temporal and frontal areas. Increasing the sample size by retrospectively pooling multi-scanner data, irrespective of the acquisition platform and parameters employed, can facilitate the identification of anatomical areas with a strong correlation between GMV changes and depression symptoms in AD patients.

Depression related cerebral pathology and its relationship with cognitive functioning: A systematic review

BACKGROUND

Depression's relationship with cerebral abnormalities and cognitive decline is temporally dynamic. Despite clear clinical utility, understanding depression's effect on cerebral structures, cognitive impairment and the interaction between these symptoms has had limited consideration.

METHODS

This review summarised studies examining a clinical depression diagnosis or validated scales measuring depressive symptoms, data concerning amyloid-beta (Aβ) levels, brain structure and function focusing on hippocampal alterations, or white matter hyperintensities (WMH), and at least one validated neuropsychological test. Online database searches of: PsycINFO, EMBASE, MEDLINE, and Scopus were conducted to identify potential articles.

RESULTS

While depression was consistently associated with cross-sectionally cognitive decline across multiple domains, the neuropathological basis of this dysfunction remained unclear. Hippocampal, frontal, and limbic dysfunction as well as cortical thinning, WMH, and Aβ burden all provide inconsistent findings, likely due to depression subtypes. The consistency of these findings additionally decreases when examining this relationship longitudinally, as these results are further confounded by pre-dementia states. The therapeutic interventions examined were more efficacious in the younger compared with the older samples, who were characterised by greater WMH and Aβ burden.

LIMITATIONS

The limited number of longitudinal and interventional studies in addition to the heterogeneity of the samples restricts their generalisability.

CONCLUSIONS

Symptomatological differences between early-onset and late-onset depression (EOD and LOD) appear crucial in understanding whether late-life depression is the primary or secondary source of cerebral pathology. Though severe cognitive impairments and clearer neuropathological underpinnings are more characteristic of LOD than EOD, the inconsistency of valid biomarkers remains problematic.

Heart rate variability biofeedback: implications for cognitive and psychiatric effects in older adults

OBJECTIVES

Two decades of heart rate variability (HRV) biofeedback research have focused on adolescent and adult populations with a variety of symptoms and conditions at the exclusion of older adults. This study explores HRV biofeedback as a novel treatment to decrease psychiatric symptoms and improve cognitive functioning in older adults.

METHODS

Participants enrolled in a three-week intervention that included six 30-min biofeedback sessions. Neuropsychological and psychiatric measures were administered before and after the intervention.

RESULTS

Decreases in depression (Cohen's d = 1.02, p < .001), state anxiety (Cohen's d = 0.82, p = .003), and trait anxiety (Cohen's d = 0.84, p = .002) were observed. An increase in attentional skills as measured by the Trail Making Test - Part A was seen (Cohen's d = 1.00, p = .001). Differences in executive skills as measured by the Trial Making Test - Part B and the Stroop Task did not reach statistical significance.

CONCLUSION

This study suggests that older adults may benefit from HRV biofeedback interventions much like the younger populations that have been studied for decades. Depression, anxiety, and attentional skills were positively affected. Several participants reported improved sleep quality and stress management. Future studies should corroborate these findings.

Investigating the relationship between age of onset of depressive disorder and cognitive function

OBJECTIVES

Depressive disorder is commonly associated with impaired cognitive function; however, it is unclear whether the age of onset of the first episode of depression, current depression severity, or historical severity of depressive episodes are associated with cognitive performance.

METHODS

This study examined baseline cross-sectional data from the ongoing online PROTECT study. A total of 7344 participants, 50 years or older, with a history of depression and no diagnosis of dementia were divided into three groups according to age of onset of their first depressive episode: early-onset, midlife-onset, and late-onset. Performance on measures of visuospatial episodic memory, executive function, verbal working, and visual working memory were evaluated. Demographic and clinical characteristics such as age, education, and severity of symptoms during their worst previous depressive episode and current depression severity were included in multivariate regression models.

RESULTS

The late-onset depression group scored significantly lower on the verbal reasoning task than the early-onset group while there were no significant differences found on the other tasks. Midlife-onset depression participants performed better in the visual episodic memory task, but worse on the verbal reasoning task, than early-onset depression participants. Current depression severity was negatively correlated with all four cognitive domains, while historical severity score was found to be significantly associated with cognitive performance on the verbal reasoning and spatial working memory tasks.

CONCLUSIONS

The most important indicator of cognitive performance in depression appears to be current, rather than historic depression severity; however, late-onset depression may be associated with more executive impairment than an early-onset depression.

Abnormal Voxel-Wise Degree Centrality in Patients With Late-Life Depression: A Resting-State Functional Magnetic Resonance Imaging Study

OBJECTIVES

Late-life depression (LLD) has negative impacts on somatic, emotional and cognitive domains of the lives of patients. Elucidating the abnormality in the brain networks of LLD patients could help to strengthen the understanding of LLD pathophysiology, however, the studies exploring the spontaneous brain activity in LLD during the resting state remain limited. This study aimed at identifying the voxel-level whole-brain functional connectivity changes in LLD patients.

METHODS

Fifty patients with late-life depression (LLD) and 33 healthy controls were recruited. All participants underwent a resting-state functional magnetic resonance imaging scan to assess the voxel-wise degree centrality (DC) changes in the patients. Furthermore, DC was compared between two patient subgroups, the late-onset depression (LOD) and the early-onset depression (EOD).

RESULTS

Compared with the healthy controls, LLD patients showed increased DC in the inferior parietal lobule, parahippocampal gyrus, brainstem and cerebellum (p < 0.05, AlphaSim-corrected). LLD patients also showed decreased DC in the somatosensory and motor cortices and cerebellum (p < 0.05, AlphaSim-corrected). Compared with EOD patients, LOD patients showed increased centrality in the superior and middle temporal gyrus and decreased centrality in the occipital region (p < 0.05, AlphaSim-corrected). No significant correlation was found between the DC value and the symptom severity or disease duration in the patients after the correction for multiple comparisons.

CONCLUSIONS

These findings indicate that the intrinsic abnormality of network centrality exists in a wide range of brain areas in LLD patients. LOD patients differ with EOD patients in cortical network centrality. Our study might help to strengthen the understanding of the pathophysiology of LLD and the potential neural substrates underlie related emotional and cognitive impairments observed in the patients.

Depressive symptoms and cognitive functioning among older adults with cancer. Aging Ment Health 2018;22:1465-1470. [PMID: 28786290 DOI: 10.1080/13607863.2017.1363868]

OBJECTIVE

The US population of older adults is growing, with an increase in diseases like cancer. As cancer rates increase, there is a concomitant increase in adverse correlates, such as cognitive impairment and depressive symptomatology. In order to develop appropriate interventions, it is vital to assess relationships among cancer, depressive symptoms and cognitive functioning.

METHODS

The sample consisted of 403 older adults with cancer diagnoses from the Health and Retirement Study. Using latent class growth analysis, longitudinal data were explored. The goals were to investigate trajectories of cognitive functioning, and to identify whether depressive symptoms and demographic factors predicted membership in the cognitive classes.

RESULTS

Three classes of cognitive functioning best fit the data: High, Middle and Low Recall, fairly stable trajectories from pre-diagnosis to a period four years after diagnosis. More depressive symptoms after diagnosis (but not prior) significantly predicted membership in the Low Recall class. Depressive symptoms did not distinguish between the High and Middle Recall classes.

CONCLUSION

Depressive symptomatology is thought to affect cognition in late life. We found that depressive symptoms after a cancer diagnosis, but not before, successfully differentiated between those who had Low Recall from those with Middle and High Recall. Implications are discussed.

Association of Brain Cortical Changes With Relapse in Patients With Major Depressive Disorder

IMPORTANCE

More than half of all patients with major depressive disorder (MDD) experience a relapse within 2 years after recovery. It is unclear how relapse affects brain morphologic features during the course of MDD.

OBJECTIVE

To use structural magnetic resonance imaging to identify morphologic brain changes associated with relapse in MDD.

DESIGN, SETTING, AND PARTICIPANTS

In this longitudinal case-control study, patients with acute MDD at baseline and healthy controls were recruited from the University of Münster Department of Psychiatry from March 21, 2010, to November 14, 2014, and were reassessed from November 11, 2012, to October 28, 2016. Depending on patients' course of illness during follow-up, they were subdivided into groups of patients with and without relapse. Whole-brain gray matter volume and cortical thickness of the anterior cingulate cortex, orbitofrontal cortex, middle frontal gyrus, and insula were assessed via 3-T magnetic resonance imaging at baseline and 2 years later.

MAIN OUTCOMES AND MEASURES

Gray matter was analyzed via group (no relapse, relapse, and healthy controls) by time (baseline and follow-up) analysis of covariance, controlling for age and total intracranial volume. Confounding factors of medication and depression severity were assessed.

RESULTS

This study included 37 patients with MDD and a relapse (19 women and 18 men; mean [SD] age, 37.0 [12.7] years), 23 patients with MDD and without relapse (13 women and 10 men; mean [SD] age, 32.5 [10.5] years), and 54 age- and sex-matched healthy controls (24 women and 30 men; mean [SD] age, 37.5 [8.7] years). A significant group-by-time interaction controlling for age and total intracranial volume revealed that patients with relapse showed a significant decline of insular volume (difference, -0.032; 95% CI, -0.063 to -0.002; P = .04) and dorsolateral prefrontal volume (difference, -0.079; 95% CI, -0.113 to -0.045; P < .001) from baseline to follow-up. In patients without relapse, gray matter volume in these regions did not change significantly (insula: difference, 0.027; 95% CI, -0.012 to 0.066; P = .17; and dorsolateral prefrontal volume: difference, 0.023; 95% CI, -0.020 to 0.066; P = .30). Volume changes were not correlated with psychiatric medication or with severity of depression at follow-up. Additional analysis of cortical thickness showed an increase in the anterior cingulate cortex (difference, 0.073 mm; 95% CI, 0.023-0.123 mm; P = .005) and orbitofrontal cortex (difference, 0.089 mm; 95% CI, 0.032-0.147 mm; P = .003) from baseline to follow-up in patients without relapse.

CONCLUSION AND RELEVANCE

A distinct association of relapse in MDD with brain morphologic features was revealed using a longitudinal design. Relapse is associated with brain structures that are crucial for regulation of emotions and thus needs to be prevented. This study might be a step to guide future prognosis and maintenance treatment in patients with recurrent MDD.

Putamen Volume Differences Among Older Adults: Depression Status, Melancholia, and Age

BACKGROUND

Individuals with major depressive disorder (MDD) may exhibit smaller striatal volumes reflecting deficits in the reward circuit. Deficits may change with age and be more pronounced among the melancholic subtype. Limited research has investigated striatal volume differences in older adults and by depression subtypes.

METHOD

We used baseline data from the Neurocognitive Outcomes of Depression in the Elderly study. We examined volumetric differences in the putamen and caudate nucleus among older adults (60 years and older), comparing healthy control participants (n = 134) to depressed participants (n = 226), and comparing nonmelancholic depressed participants (n = 93) to melancholic depressed participants (n = 133). Group-by-age interactions were examined.

RESULTS

There were no significant group differences for the caudate nucleus. For the left putamen, investigation of the significant group-by-age interaction revealed that volume size was greater for the healthy controls compared to the depressed participants but only at younger ages (60-65 years); group differences diminished with increasing age. Examining volume by depression subtype revealed that the melancholic depressed participants had a smaller left putamen compared to the nonmelancholic depressed participants. Anhedonia symptoms were related to both smaller left and right putamen.

CONCLUSION

Structural abnormalities in reward regions may underlie the anhedonic phenotype. Volume loss associated with MDD may attenuate in older age.

Longitudinal Cognitive Outcomes of Clinical Phenotypes of Late-Life Depression

OBJECTIVE

Late-life depression is associated with cognitive deficits and increased risk for cognitive decline. The purpose of the study was to determine whether clinical characteristics could serve as phenotypes informative of subsequent cognitive decline. Age at depression onset and antidepressant remission at 3 months (acute response) and 12 months (chronic response) were examined.

METHODS

In a longitudinal study of late-life depression in an academic center, 273 depressed and 164 never-depressed community-dwelling elders aged 60 years or older were followed on average for over 5 years. Participants completed annual neuropsychological testing. Neuropsychological measures were converted to z-scores derived from the baseline performance of all participants. Cognitive domain scores at each time were then created by averaging z-scores across tests, grouped into domains of episodic memory, attention-working memory, verbal fluency, and executive function.

RESULTS

Depressed participants exhibited poorer performance at baseline and greater subsequent decline in all domains. Early-onset depressed individuals exhibited a greater decline in all domains than late-onset or nondepressed groups. For remission, remitters and nonremitters at both 3 and 12 month exhibited greater decline in episodic memory and attention-working memory than nondepressed subjects. Three-month remitters also exhibited a greater decline in verbal fluency and executive function, whereas 12-month nonremitters exhibited greater decline in executive function than other groups.

CONCLUSION

Consistent with past studies, depressed elders exhibit greater cognitive decline than nondepressed subjects, particularly individuals with early depression onset, supporting the theory that repeated depressive episodes may contribute to decline. Clinical remission is not associated with less cognitive decline.

Cerebral blood flow changes in remitted early- and late-onset depression patients

Abnormal cerebral blood flow (CBF) is reportedly associated with major depressive disorder (MDD). We have investigated CBF changes in early-onset depression (EOD) and late-onset depression (LOD), and their impact on cognitive function. Thirty-two remitted EOD patients, 32 remitted LOD patients, and 43 age-matched healthy controls were recruited, and the pulsed arterial spin labeling data were scanned under 3.0T MRI and processed through voxel-by-voxel statistical analysis. Compared to healthy controls, LOD patients had decreased normalized CBF in the bilateral precuneus, cuneus, right fronto-cingulate-striatal areas, and right temporal, occipital and parietal lobes, but increased normalized CBF in the left frontal and temporal cortices and the cingulate gyrus. EOD patients had decreased normalized CBF in the left cerebellum and right calcarine/lingual/fusiform gyrus, and increased normalized CBF in right angular gyrus. LOD patients displayed hemispheric asymmetry in CBF, and had more regions with abnormal CBF than EOD patients. A significant correlation between abnormal CBF and impaired cognitive function was detected in LOD patients, but not EOD patients. These results demonstrate greater CBF abnormalities in LOD patients than EOD patients, and suggest these CBF changes may be associated with progressive degradation of cognitive function in LOD patients.

Comparing the Immune-Genomic Effects of Vilazodone and Paroxetine in Late-Life Depression: A Pilot Study

Vilazodone is a novel antidepressant agent that combines selective serotonin (5-HT) reuptake inhibitor (SSRI) activity and 5-HT(1A) receptor partial agonist activity. A pilot study was conducted to compare vilazodone (novel compound) and paroxetine (gold standard) on antidepressant effects, tolerability, and inflammation and immune modulation. A 12-week, double-blind, randomized clinical trial was conducted with 56 nondemented older adults diagnosed with major depressive disorder (MDD). Between-group differences in mood, tolerability, and safety, as well as genomic markers of inflammation and immune modulation, were examined. Both treatment groups demonstrated similar improvement in depressed mood. Leukocyte gene expression profiles demonstrated reduction of specific proinflammatory gene transcripts and bioinformatic indications of reduced nuclear factor kappa B (NF-κB), activator protein (AP)-1, and cAMP response element binding (CREB) activity in the vilazodone group compared to the paroxetine group. Transcript origin analyses implicated monocytes and dendritic cells as the primary cellular origins of transcript reductions in the vilazodone-treated group. Vilazodone's antidepressant effects may be associated with reduction of proinflammatory gene expression and immune modulation. Further research is required.

Early- and Late-Onset Depression in Late Life: A Prospective Study on Clinical and Structural Brain Characteristics and Response to Electroconvulsive Therapy

OBJECTIVE

The clinical profile of late-life depression (LLD) is frequently associated with cognitive impairment, aging-related brain changes, and somatic comorbidity. This two-site naturalistic longitudinal study aimed to explore differences in clinical and brain characteristics and response to electroconvulsive therapy (ECT) in early- (EOD) versus late-onset (LOD) late-life depression (respectively onset <55 and ≥55 years).

METHODS

Between January 2011 and December 2013, 110 patients aged 55 years and older with ECT-treated unipolar depression were included in The Mood Disorders in Elderly treated with ECT study. Clinical profile and somatic health were assessed. Magnetic resonance imaging (MRI) scans were performed before the first ECT and visually rated.

RESULTS

Response rate was 78.2% and similar between the two sites but significantly higher in LOD compared with EOD (86.9 versus 67.3%). Clinical, somatic, and brain characteristics were not different between EOD and LOD. Response to ECT was associated with late age at onset and presence of psychotic symptoms and not with structural MRI characteristics. In EOD only, the odds for a higher response were associated with a shorter index episode.

CONCLUSION

The clinical profile, somatic comorbidities, and brain characteristics in LLD were similar in EOD and LOD. Nevertheless, patients with LOD showed a superior response to ECT compared with patients with EOD. Our results indicate that ECT is very effective in LLD, even in vascular burdened patients.

Gender and age group differences in suicide risk associated with co-morbid physical and psychiatric disorders in older adults

BACKGROUND

It is unclear whether health service use influences the association between psychiatric and physical co-morbidity and suicide risk in older adults.

METHODS

Controls were older adults (n = 2,494) participating in a longitudinal study on the health of the elderly carried out between 2004 and 2007, in Quebec. The cases were all suicide decedents (n = 493) between 2004 and 2007, confirmed by the Quebec Coroner's office. Multivariate analyses were carried out to test the association between suicide and the presence of psychiatric and physical illnesses controlling for health service use and socio-demographic factors by gender and age group. Interaction terms were also tested between suicide and co-morbidity on outpatient service use.

RESULTS

The presence of physical illnesses only, was associated with a reduced risk of suicide across all sex and age groups. The presence of a mental disorder only was associated with an increased risk of suicide overall and specifically in females and those aged 70 to 84 years of age. Suicide risk was lower in those with a psychiatric and physical co-morbidity and consulting mental health services.

CONCLUSIONS

Increased mental health follow-up in older adults with psychiatric illnesses is needed for the detection of suicidal behavior and reducing suicide risk in males. Further research should focus on the mitigating effect of the presence of physical illnesses on stigma and health service use and the presence of social support in the elderly.

Disrupted Interhemispheric Synchrony in Default Mode Network Underlying the Impairment of Cognitive Flexibility in Late-Onset Depression

The intuitive association between cognitive impairment and aberrant functional activity in the brain network has prompted interest in exploring the role of functional connectivity in late-onset depression (LOD). The relationship of altered voxel-mirrored homotopic connectivity (VMHC) and cognitive dysfunction in LOD is not yet well understood. This study was designed to examine the implicit relationship between the disruption of interhemispheric functional coordination and cognitive impairment in LOD. LOD patients (N = 31) and matched healthy controls (HCs; N = 37) underwent neuropsychological tests and functional magnetic resonance imaging (fMRI) in this study. The intergroup difference of interhemispheric coordination was determined by calculating VMHC value in the whole brain. The neuro-behavioral relevancy approach was applied to explore the association between disrupted VMHC and cognitive measures. Receiver operating characteristic (ROC) curve analysis was used to determine the capability of disrupted regional VMHC to distinguish LOD. Compared to the HC group, significantly attenuated VMHC in the superior frontal gyrus (SFG), superior temporal gyrus (STG), posterior cerebellar lobe (CePL) and post- and precentral gyri were observed in the bilateral brain of LOD patients. The interhemispheric asynchrony in bilateral CePLs was positively correlated with the performance of trail making test B (TMT-B) in LOD patients (r = 0.367, P = 0.040). ROC analysis revealed that regions with abnormal VMHC could efficiently distinguish LOD from HCs (Area Under Curve [AUC] = 0.90, P < 0.001). Altered linkage patterns of intrinsic homotopic connectivity and impaired cognitive flexibility was first investigated in LOD, and it would provide a novel clue for revealing the neural substrates underlying cognitive impairment in LOD.

[Late-onset depression : Pathophysiology, diagnostics and treatment]

Late-onset depression (LOD) is defined as depression manifesting for the first time in later life. Up to now, there has been no exact definition of the lower age limit for LOD. Psychopathological symptoms of LOD do not fundamentally differ from depression in other phases of life; however, cognitive deficits are typically more pronounced. The LOD is associated with an increased risk of developing dementia. Imaging studies show reduction in gray matter volume and white matter lesions caused by vascular diseases. The occurrence of depression with vascular lesions of the brain is also referred to as "vascular depression". The diagnostic procedure includes a detailed medical history and the observation of psychopathological changes, physical examination, laboratory tests, electroencephalograph (EEG), electrocardiograph (ECG) and magnetic resonance imaging (MRI) of the head and neuropsychological tests to measure cognitive deficits. Psychotherapy is an effective treatment option. Selective serotonin reuptake inhibitors are the first-line pharmacological therapy.

Combined treatment with memantine/es-citalopram for older depressed patients with cognitive impairment: a pilot study

OBJECTIVE

The objective of the study is to assess combined antidepressant and memantine treatment in older patients presenting with depression and cognitive impairment.

METHODS

Thirty-five depressed patients with cognitive impairment participated in this open-label pilot study. We evaluated whether, over a 48-week period, combined antidepressant (primarily es-citalopram) and memantine treatment was effective in the treatment of cognitive impairment and depression. Neuropsychological testing was performed, and antidepressant response monitored at baseline and at the 12, 24, and 48-week time points.

RESULTS

Treatment with escitalopram (mean daily dose 18.62 mg, SD 5.15) and memantine (mean daily dose 13.62 mg, SD 6.67) was associated with improvement in Hamilton Depression Rating Scale scores over the 48-week study period. Patients demonstrated significant improvement in the primary outcome of cognitive performance (Selective Reminding Test total immediate recall; SRT-IR) over the 48-week treatment period (p = 0.0147). Significant improvement was also observed in measures of naming and verbal fluency but not in the other cognitive domains. One of the 35 patients (2.9%) converted to Alzheimer's disease over the 48-week treatment period. In the amnestic mild cognitive impairment subsample (n = 22), the conversion rate was 4.5%, a rate lower than in other reports of patients with DEP-CI.

CONCLUSIONS

In this open-label trial, combined antidepressant and memantine treatment in patients with DEP-CI was associated with improved cognition and a low rate of conversion to dementia compared with published studies in patients with DEP-CI. Although limited by the open-label study design that incorporates practice effects that can improve cognitive test performance, the findings suggest the need for a larger randomized placebo-controlled trial.

The double burden of age and major depressive disorder on the cognitive control network

Poor cognitive control (CC) is common among older individuals with major depressive disorder (OMDD). At the same time, studies of CC in OMDD with fMRI are relatively limited and often have small samples. The present study was conducted to further examine poor CC in OMDD with early onset depression, as well as to investigate the interactive effects of MDD and aging on cognitive control. Twenty OMDD, 17 older never-depressed comparisons (ONDC), 16 younger adults with MDD (YMDD), and 18 younger never-depressed comparisons (YNDC) participated. All participants completed the Go level of the Parametric Go/No-Go Test, which requires sustained attention and inhibitory control while undergoing functional MRI (fMRI). YNDC were faster in reaction times (RTs) to go targets relative to the other 3 groups, and the YMDD group was faster than the OMDD group. fMRI effects of both age and diagnosis were present, with greater activation in MDD, and in aging. Additionally, the interaction of age and MDD was also significant, such that OMDD exhibited greater recruitment of fronto-subcortical regions relative to older comparisons. These results are consistent with prior research reporting that OMDD recruit more fronto-striatal regions in order to perform at the same level as their never-depressed peers, here on a task of sustained attention and inhibitory control. There may be an interaction of cognitive aging and depression to create a double burden on the CC network in OMDD, including possible fronto-striatal compensation during CC that is unique to OMDD, as younger MDD individuals do not show this pattern.

Dual Trajectories of Depression and Cognition: A Longitudinal Population-Based Study

OBJECTIVE

To examine the relationships over time between dual trajectories of depressive symptoms and several cognitive domains.

METHODS

In a 5-year longitudinal study, 1,978 randomly selected individuals aged 65+ years at recruitment were assessed annually. Repeated measures were of depressive symptoms on the modified Center for Epidemiologic Studies Depression Scale and composite scores in the cognitive domains of attention, executive function, memory, language, and visuospatial function. Latent class trajectories were identified for depression and for each cognitive domain and their associations investigated using dual trajectory modeling. Cognitive trajectories with z scores below -1 were designated as persistently low.

RESULTS

Five depressive symptom trajectories were observed: rarely depressed (60.5%); low-grade, decreasing symptoms (18.5%); low-grade, increasing symptoms (9.6%); moderate-grade symptoms (7.4%); and consistent higher-grade symptoms (4.0%). For each cognitive domain six trajectories were observed. The rarely depressed and low-grade decreasing symptom groups were the least likely to have persistently low cognition. The symptom trajectory most strongly associated with persistently low functioning in each domain was not the higher-grade group but rather the low-grade increasing group in the case of attention and the moderate-grade trajectory in the other four domains.

CONCLUSION

Consistently higher-grade depressive symptoms are less strongly associated with poor cognitive functioning than with either moderate- or low-grade increasing depressive symptom trajectories, over time and across different domains. Examining both depression and cognition longitudinally allows heterogeneity of both to be addressed, revealing latent groups with potential diagnostic and prognostic implications.

Physical frailty in late-life depression is associated with deficits in speed-dependent executive functions

OBJECTIVE

The aim of this study was to examine the association between physical frailty and neurocognitive performance in late-life depression (LLD).

METHODS

Cross-sectional design using baseline data from a treatment study of late-life depression was used in this study. Individuals aged 60 years and older were diagnosed with major depressive disorder at time of assessment (N = 173). All participants received clinical assessment of depression and completed neuropsychological testing during a depressive episode. Physical frailty was assessed using an adaptation of the FRAIL scale. Neuropsychological domains were derived from a factor analysis that yielded three factors: (i) speeded executive and fluency, (ii) episodic memory, and (iii) working memory. Associations were examined with bivariate tests and multivariate models.

RESULTS

Depressed individuals with a FRAIL score >1 had worse performance than nonfrail depressed across all three factors; however, speeded executive and fluency was the only factor that remained significant after controlling for depression symptom severity and demographic characteristics.

CONCLUSIONS

Although physical frailty is associated with broad neurocognitive deficits in LLD, it is most robustly associated with deficits in speeded executive functions and verbal fluency. Causal inferences are limited by the cross-sectional design, and future research would benefit from a comparison group of nondepressed older adults with similar levels of frailty. Research is needed to understand the mechanisms underlying associations among depression symptoms, physical frailty, and executive dysfunction and how they are related to the cognitive and symptomatic course of LLD.

Comparison of Clock Test Deficits Between Elderly Patients With Early and Late Onset Depression

To compare clock test deficits in elderly patients with early onset depression (EOD) and late onset depression (LOD), we assessed 32 elderly healthy controls (HCs), 26 patients with EOD, and 27 patients with LOD with the clock drawing test (CDT), clock setting test, clock reading test, and the Tübingen Clock Questionnaire testing semantic memory about clock times. There was no significant difference in depression severity between patients with EOD and LOD. Patients with LOD had significantly lower scores on the CDT than patients with EOD and HCs. Semantic memory impairment concerning minute hand functionality was highly correlated with CDT performance and was significantly different between the EOD and the LOD groups. It can be suggested that significant differences in cognitive impairment severity between patients with EOD and LOD can be detected with CDT. Semantic memory impairment concerning minute hand functionality might affect CDT test results in elderly patients with depression.

The course of depression in late life as measured by the Montgomery and Asberg Depression Rating Scale in an observational study of hospitalized patients

BACKGROUND

Depression and depressive symptoms are highly prevalent in old persons but are potentially reversible. Full recovery is the main goal in the treatment of depressive episodes. Compared to clinical trials, observational studies of patients with depression in late life (DLL) show poorer prognoses in terms of response and remission. However, observational studies on the course of DLL are scarce. The aims of this study were to examine the course of DLL in terms of response, remission and symptom-specific changes as measured by the Montgomery and Asberg Depression Rating Scale (MADRS), and to explore which clinical variables were associated with the response and remission.

METHODS

This is an observational, multicenter and prospective study of patients aged 60 years and older who were referred to treatment of depression in the department of old-age psychiatry at specialist health care services in Norway. The patients were evaluated with the MADRS at admission to and discharge from hospital. The mean, median, minimum and maximum values for days stayed in hospital were 68, 53, 16 and 301, respectively. Effect size (ES) was calculated to determine which MADRS symptoms changed most during the treatment. To assess the predictors for change in the MADRS score (continuous variable) and for remission and response (both dichotomous variables), regression models adjusting for cluster effects within center were estimated.

RESULTS

Of 145 inpatients, 99 (68.3 %) had a response to treatment (50 % or more improvement of the MADRS score). Remission (MADRS score ≤9 at discharge) was experienced in 74 (51.0 %) of the patients. Of the individual MADRS items, "reported sadness" (ES =0.88) and "lassitude" (ES = 0.80) showed the greatest amount of improvement, and "concentration difficulties" (ES = 0.50) showed the least amount of improvement during treatment. Having a diagnosis of dementia was associated with a lower remission rate and less improvement in the MADRS score during the treatment. Poorer physical health was associated with a lower response rate. Having experienced previous episode(s) of depression was associated with a lower remission rate.

CONCLUSIONS

Recurrent episodes of depression, poor somatic health and a diagnosis of dementia were found to be negative prognostic factors for the course of DLL. Clinicians should therefore pay close attention to these factors when evaluating treatment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01952366.