The association of anxiety and depression with future dementia diagnosis: a case-control study in primary care

Memory self-efficacy and working memory

Dementia affects multiple aspects of cognitive functioning, including working memory and executive functioning. Memory self-efficacy (MSE) has previously been related to episodic memory performance and to executive functioning, but little research has examined the relations between MSE and working memory. United States older adults (N  = 197) were recruited via MTurk to complete an MSE questionnaire before completing a digit span working memory task. Hierarchical regression results revealed that the model accounted for a significant amount of variance in working memory performance after statistically controlling for several covariates, F(11, 179) = 4.94, p < .001, adjusted R2 = .19. MSE explained a large and unique portion of variance (B = 1.02, SE = 0.17, p < .001). Based on our findings, one's beliefs about their memory are positively associated with their working memory performance. These novel findings provide support for neuropsychologists to consider using MSE measures and utilizing MSE interventions.

Hypothalamic-pituitary-adrenal (HPA) axis activity and anxiety-like behavior during aging: A test of the glucocorticoid cascade hypothesis in amyloidogenic APPswe/PS1dE9 mice

Alzheimer's disease (AD) is a progressive, dementing, whole-body disorder that presents with decline in cognitive, behavioral, and emotional functions, as well as endocrine dysregulation. The etiology of AD is not fully understood but stress- and anxiety-related hormones may play a role in its development and trajectory. The glucocorticoid cascade hypothesis posits that levels of glucocorticoids increase with age, leading to dysregulated negative feedback, further elevated glucocorticoids, and resulting neuropathology. We examined the impact of age (from 2 to 10 months) and stressor exposure (predator odor) on hormone levels (corticosterone and ghrelin), anxiety-like behavior (open field and light dark tests), and memory-related behavior (novel object recognition; NOR), and whether these various measures correlated with neuropathology (hippocampus and cortex amyloid beta, Aβ) in male and female APPswe/PS1dE9 transgenic and non-transgenic mice. Additionally, we performed exploratory analyses to probe if the open field and light dark test as commonly used tasks to assess anxiety levels were correlated. Consistent with the glucocorticoid cascade hypothesis, baseline corticosterone increased with age. Predator odor exposure elevated corticosterone at each age, but in contrast to the glucocorticoid cascade hypothesis, the magnitude of stressor-induced elevations in corticosterone levels did not increase with age. Overall, transgenic mice had higher post-stressor, but not baseline, corticosterone than non-transgenic mice, and across both genotypes, females consistently had higher (baseline and post-stressor) corticosterone than males. Behavior in the open field test primarily showed decreased locomotion with age, and this was pronounced in transgenic females. Anxiety-like behaviors in the light dark test were exacerbated following predator odor, and female transgenic mice were the most impacted. Compared to transgenic males, transgenic females had higher Aβ concentrations and showed more anxiety-like behavior. Performance on the NOR did not differ significantly between genotypes. Lastly, we did not find robust, statistically significant correlations among corticosterone, ghrelin, recognition memory, anxiety-like behaviors, or Aβ, suggesting outcomes are not strongly related on the individual level. Our data suggest that despite Aβ accumulation in the hippocampus and cortex, male and female APPswePS1dE9 transgenic mice do not differ robustly from their non-transgenic littermates in physiological, endocrine, and behavioral measures at the range of ages studied here.

Economic Burden of Dementia Caused by Cardiovascular Disease in Australia

Background: The established link between cardiovascular disease (CVD) and dementia may provide new insights into dementia prevention. Objective: It aims to quantify the burden of dementia attributable to people with CVD. Methods: A Markov microsimulation model was developed to simulate the lifetime cost and quality-adjusted life-years (QALYs) related to people with and without CVD in Australia. A de-novo systematic review was undertaken to identify all evidence around the association between CVD [i.e., stroke, myocardial infarction (MI), atrial fibrillation (AF), and heart failure (HF)] and the risk of developing dementia. Incremental costs and QALY losses were estimated for people by type of CVD compared to the general Australian population without CVD. Results: Of the comprehensive literature search, 19 observational studies were included in the qualitative synthesis. Patients who had CVD incurred both higher healthcare costs over their lifetime (ranging from $73,131 for patients with AF to $127,396 for patients with HF) and fewer QALYs gains (from –1.099 for patients with MI to –5.163 for patients with stroke), compared to people who did not have CVD. The total incremental economic burden of dementia from patients aged 65 years and over with CVD was $6.45 billion (stroke), $11.89 billion (AF), $17.57 billion (MI), or $7.95 billion (HF) over their remaining life expectancy. Conclusion: The results highlighted the importance of CVD prevention to reduce the CVD burden and decrease the prevalence of dementia. Interventions that target patients with dementia risk factors like CVD may prove to be effective and cost-effective strategies.

Comparative differences in musculoskeletal pain consultation and analgesic prescription for people with dementia: a UK-wide matched cohort study

ABSTRACT

Painful musculoskeletal conditions are common in older adults; however, pain identification, assessment, and management are reported to be suboptimal for people with dementia. Adequate pain management is an integral aspect of care for people with dementia to prevent or delay negative outcomes, such as behavioural and psychological changes, emergency department attendance, and premature nursing home admission. This study aims to examine musculoskeletal consultations and analgesic prescriptions for people with dementia compared with those for people without dementia. A dementia cohort (n = 36,582) and matched cohort were identified in the Clinical Practice Research Datalink (a UK-wide primary care database). Period prevalence for musculoskeletal consultations and analgesic prescriptions was described, and logistic regression applied to estimate associations between dementia and musculoskeletal consultation or analgesic prescription from the time of dementia diagnosis to 5 years after diagnosis. People with dementia had a consistently (over time) lower prevalence and odds of musculoskeletal consultation and analgesic prescription compared with people without dementia. The evidence suggests that pain management may be suboptimal for people with dementia. These results highlight the need to increase awareness of pain and use better methods of pain assessment, evaluation of treatment response, and acceptable and effective management for people with dementia, in primary care.

Markers of dementia-related health in primary care electronic health records

OBJECTIVES

Identifying routinely recorded markers of poor health in patients with dementia may help treatment decisions and evaluation of earlier outcomes in research. Our objective was to determine whether a set of credible markers of dementia-related health could be identified from primary care electronic health records (EHR).

METHODS

The study consisted of (i) rapid review of potential measures of dementia-related health used in EHR studies; (ii) consensus exercise to assess feasibility of identifying these markers in UK primary care EHR; (iii) development of UK EHR code lists for markers; (iv) analysis of a regional primary care EHR database to determine further potential markers; (v) consensus exercise to finalise markers and pool into higher domains; (vi) determination of 12-month prevalence of domains in EHR of 2328 patients with dementia compared to matched patients without dementia.

RESULTS

Sixty-three markers were identified and mapped to 13 domains: Care; Home Pressures; Severe Neuropsychiatric; Neuropsychiatric; Cognitive Function; Daily Functioning; Safety; Comorbidity; Symptoms; Diet/Nutrition; Imaging; Increased Multimorbidity; Change in Dementia Drug. Comorbidity was the most prevalent recorded domain in dementia (69%). Home Pressures were the least prevalent domain (1%). Ten domains had a statistically significant higher prevalence in dementia patients, one (Comorbidity) was higher in non-dementia patients, and two (Home Pressures, Diet/Nutrition) showed no association with dementia.

CONCLUSIONS

EHR captures important markers of dementia-related health. Further research should assess if they indicate dementia progression. These markers could provide the basis for identifying individuals at risk of faster progression and outcome measures for use in research.

Indicators of dementia disease progression in primary care: An electronic health record cohort study

BACKGROUND AND PURPOSE

The objectives were to assess the feasibility and validity of using markers of dementia-related health as indicators of dementia progression in primary care, by assessing the frequency with which they are recorded and by testing the hypothesis that they are associated with recognised outcomes of dementia. The markers, in 13 domains, were derived previously through literature review, expert consensus, and analysis of regional primary care records.

METHODS

The study population consisted of patients with a recorded dementia diagnosis in the Clinical Practice Research Datalink, a UK primary care database linked to secondary care records. Incidence of recorded domains in the 36 months after diagnosis was determined. Associations of recording of domains with future hospital admission, palliative care, and mortality were derived.

RESULTS

There were 30,463 people with diagnosed dementia. Incidence of domains ranged from 469/1000 person-years (Increased Multimorbidity) to 11/1000 (Home Pressures). An increasing number of domains in which a new marker was recorded in the first year after diagnosis was associated with hospital admission (hazard ratio for ≥4 domains vs. no domains = 1.24; 95% confidence interval = 1.15-1.33), palliative care (1.87; 1.62-2.15), and mortality (1.57; 1.47-1.67). Individual domains were associated with outcomes with varying strengths of association.

CONCLUSIONS

Feasibility and validity of potential indicators of progression of dementia derived from primary care records are supported by their frequency of recording and associations with recognised outcomes. Further research should assess whether these markers can help identify patients with poorer prognosis to improve outcomes through stratified care and targeted support.

Anxiety and psychological management of heart disease and heart surgery

Anxiety is associated with many forms and facets of heart disease, and, by extension, neurologic manifestations of heart disease. Despite its seeming self-evidence, anxiety is challenging to consistently define, measure, and operationalize in the context of medical research. Various diagnostic nosologies have been defined and refined over time, but anxiety is also a universal human experience that may be "normal" in many circumstances, particularly in the face of major medical issues. For these and other reasons, the research on anxiety and heart disease is mixed, incomplete, and often characterized by challenging questions of causality. Nonetheless, a broad body of literature has established clear connections between anxiety and vascular risk factors, cardiac disease, and cardiac surgery. These relationships are often intuitive, with research suggesting, for example, that chronic activation of the sympathetic nervous system is associated with increased risk of heart disease. However, they are sometimes complexly reciprocal or even surprising (e.g., with high-anxiety individuals found to have better outcomes in some cardiac conditions by virtue of seeking evaluation and treatment earlier). This chapter reviews the construct of anxiety and its complexities, its associations with heart disease, and the established treatments for anxiety, concluding with questions about anxiety, heart disease, and their optimal management that still need to be answered.

Internalize at your peril: internalizing disorders as risk factors for dementia-cohort study

Few studies examined comorbid anxiety and depression's independent association with dementia. We assessed internalizing disorders as risk factors for dementia to avoid pitfalls inherent in separating anxiety and depression. Retrospectively designed prospective comparative cohort study using New Zealand's (NZ) National Minimum Dataset of hospital discharges. Hazards ratios (HRs), estimated from parametric survival models, compared the time to incident dementia after a minimal latency interval of 10 years between those with and without prior diagnosis of an internalizing disorder. A total of 47,932 patients aged 50-54 years were discharged from a publicly funded hospital events in NZ between 1988 and 1992. Of these, 37,631 (79%) met eligibility criteria, and incident dementia was diagnosed in 1594. Rates of incident dementia were higher among patients with an earlier diagnosis of internalizing disorders (572 vs 303 per 100,000 person years at risk (PYAR)). After adjustment for age, sex, ethnicity, and region, those with internalizing disorders were estimated to have a higher risk of developing dementia than those without (adjusted HR = 1.57, 95% CI 1.17-2.10). Females with an earlier diagnosis of internalizing disorders were estimated to have almost twice the risk of developing dementia (adjusted HR 1.80, 95% CI 1.25-2.59). Internalizing disorders affect one in five adults globally. Our findings suggest a significant increase in risk of dementia more than 10 years after the diagnosis of internalizing disorder.

Are symptoms of insomnia in primary care associated with subsequent onset of dementia? A matched retrospective case-control study

Objective: There is evidence from neuroimaging studies of an association between insomnia and early dementia biomarkers, but observational studies have so far failed to show a clear association between insomnia and the later development of dementia. We investigated the association between dementia diagnosis and recording of insomnia symptoms 5-10 years earlier in primary care.Method: A case-control study using data from the Clinical Practice Research Datalink. 15,209 cases with dementia (either Alzheimer's, vascular, mixed or non-specific subtypes) at least 65 years old at time of diagnosis, were matched with the same number of controls on year of birth and gender. We ascertained the presence of insomnia symptoms during a five-year period starting 10 years before the index date. Odds ratios for developing dementia were estimated using logistic regression after controlling for hypnotic exposure and physical and mental health comorbidities.Results: The adjusted odds ratio for dementia in those with previous insomnia was 1.34 (95% CI = 1.20-1.50).Conclusion: There is an association between dementia and previous insomnia. It may be possible to incorporate insomnia into predictive tools for dementia.

Social isolation, cognitive reserve, and cognition in older people with depression and anxiety

Objectives: Poor social connections may be associated with poor cognition in older people who are not experiencing mental health problems, and the trajectory of this association may be moderated by cognitive reserve. However, it is unclear whether this relationship is the same for older people with symptoms of depression and anxiety. This paper aims to explore social relationships and cognitive function in older people with depression and anxiety. Method: Baseline and two-year follow-up data were analysed from the Cognitive Function and Ageing Study-Wales (CFAS-Wales). We compared levels of social isolation, loneliness, social contact, cognitive function, and cognitive reserve at baseline amongst older people with and without depression or anxiety. Linear regression was used to assess the relationship between isolation and cognition at baseline and two-year follow-up in a subgroup of older people meeting pre-defined criteria for depression or anxiety. A moderation analysis tested for the moderating effect of cognitive reserve. Results: Older people with depression or anxiety perceived themselves as more isolated and lonely than those without depression or anxiety, despite having an equivalent level of social contact with friends and family. In people with depression or anxiety, social isolation was associated with poor cognitive function at baseline, but not with cognitive change at two-year follow-up. Cognitive reserve did not moderate this association. Conclusion: Social isolation was associated with poor cognitive function at baseline, but not two-year follow-up. This may be attributed to a reduction in mood-related symptoms at follow-up, linked to improved cognitive function.

The Diagnosis and Treatment of Anxiety Disorders

BACKGROUND

Anxiety disorders are the most common type of mental illness in Europe, with a 12-month prevalence of 14% among persons aged 14 to 65. Their onset is usually in adolescence or early adulthood. The affected patients often develop further mental or somatic illnesses (sequential comorbidity).

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed.

RESULTS

The group of anxiety disorders includes generalized anxiety disorder (GAD), phobic disorders, panic disorders, and two disorders that are often restricted to childhood-separation anxiety and selective mutism. A comprehensive differential diag- nostic evaluation is essential, because anxiety can be a principal manifestation of other types of mental or somatic illness as well. Psychotherapy and treatment with psychoactive drugs are the therapeutic strategies of first choice. Of all types of psycho- therapy, cognitive behavioral therapy has the best documented efficacy. Modern antidepressants are the drugs of first choice for the treatment of panic disorders, agoraphobia, social phobia, and GAS; pregabalin is a further drug of first choice for GAS.

CONCLUSION

In general, anxiety disorders can now be effectively treated. Patients should be informed of the therapeutic options and should be involved in treatment planning. Current research efforts are centered on individualized and therefore, it is hoped, even more effective treatment approaches than are available at present.

Anxiety as a Risk Factor for Cognitive Decline: A 12-Year Follow-Up Cohort Study

OBJECTIVE

Anxiety might be a risk factor for cognitive decline, but previous studies had short follow-up or small sample sizes or studied general or single cognitive domain functioning.

METHODS

Anxiety symptoms were assessed with the Symptom Checklist-90 in 918 participants of the Maastricht Aging Study aged 50 years or older. Anxiety was analyzed both dichotomously (highest versus lower quartiles as a group) and continuously. Neuropsychological tests measured executive function, memory, speed of information processing, and verbal fluency. Linear mixed models were conducted with anxiety symptoms as predictor and change in cognitive scores as outcome. Differences of associations by age and gender were studied with three-way interactions.

RESULTS

Higher anxiety symptoms were significantly associated with more decline in verbal memory in those aged 65 years and older (delayed recall: χ² = 9.30, df = 2, p = 0.01; immediate recall: χ² = 11.81, df = 2, p = 0.003). There were sex differences in executive function (χ² = 6.63, df = 2, p = 0.036), fluency (χ² = 6.89, df = 2, p = 0.032), and processing speed (χ² = 8.83, df = 2, p = 0.012), with lower performance in women over time.

CONCLUSION

In participants without cognitive impairments at baseline, anxiety symptoms were associated with a decline in verbal memory in older adults and with poorer performance in nonamnestic domains in women. Adequate treatment of anxiety symptoms could have a beneficial influence on the risk of developing neurodegenerative diseases. Further research is needed to elucidate whether this association is causal.

Genetic and Environmental Associations Among Executive Functions, Trait Anxiety, and Depression Symptoms in Middle Age

Multiple executive functions (EFs) are associated with trait anxiety and depression symptoms, but it is unclear how genetic and/or environmental factors account for these associations, and if they are explained by general variance underlying multiple EFs (i.e., Common EF). In this study, 1207 male twins completed seven EF tasks and measures of trait anxiety and depression symptoms at average age 62. The Common EF factor was associated with both anxiety (r= -.25) and depression symptoms (r= -.35). Anxiety and depression had near complete genetic overlap (r g=.96). Genetic influences shared with depression accounted for 83% of the phenotypic correlation between anxiety and Common EF. For depression, the phenotypic correlation with Common EF was explained by genetic influences shared with anxiety (69%), but also nonshared environmental influences distinct from anxiety (20%). These results suggest that genetic influences on Common EF play a role in the observed genetic overlap between anxiety and depression.

Smoking and Obesity as Risk Factors in Frontotemporal Dementia and Alzheimer's Disease: The HUNT Study

BACKGROUND

Few studies have assessed smoking and obesity together as risk factors for frontotemporal dementia (FTD) and Alzheimer's disease (AD).

OBJECTIVE

To study smoking and obesity as risk factors for FTD and AD.

METHODS

Ninety patients with FTD and 654 patients with AD were compared with 116 cognitively healthy elderly individuals in a longitudinal design with 15-31 years between measurements of risk factors before the dementia diagnosis.

RESULTS

There were no associations between smoking and FTD (p = 0.218; odds ratio [OR]: 0.990; 95% confidence interval [CI]: 0.975-1.006). There were significant associations between obesity and FTD (p = 0.049; OR: 2.629; 95% CI: 1.003-6.894). There were significant associations between both smoking (p = 0.014; OR: 0.987; 95% CI: 0.977-0.997) and obesity (p = 0.015; OR: 2.679; 95% CI: 1.211-5.928) and AD.

CONCLUSION

Our findings suggest that obesity is a shared risk factor for FTD and AD, while smoking plays various roles as a risk factor for FTD and AD.

Clinically significant anxiety as a risk factor for dementia in the elderly community

OBJECTIVE

To evaluate whether clinically significant anxiety is an independent risk factor for dementia, taking into account both depression among potentially confounding factors and the competing risk of death.

METHOD

During the Zaragoza Dementia and Depression (ZARADEMP) study, a random sample of community dwellers aged 55 years or older was assessed (n = 4803), and a two-wave, 4.5-year follow-up was completed. Geriatric Mental State (GMS)-AGECAT criteria were used to diagnose anxiety and DSM-IV criteria were applied to diagnose incident dementia. The multivariate Fine and Gray regression model was implemented to calculate dementia risk.

RESULTS

Compared with non-cases (GMS-AGECAT criteria), the incidence rate of dementia was significantly higher in subcases of anxiety, and particularly significant in the cases of anxiety (incidence rate ratio (IRR): 2.77; P = 0.010). Cases of anxiety, but not subcases, at baseline were significantly associated with dementia risk (adjusted subdistribution hazard ratio (SHR): 2.7; P = 0.019).

CONCLUSION

Clinically significant anxiety is associated with an almost threefold increase in the risk of dementia in the population, even when controlling for depression and considering mortality in the competing risks model.

Anxiety and Depression as Risk Factors in Frontotemporal Dementia and Alzheimer's Disease: The HUNT Study

Background

The roles of both anxiety and depression as risk factors for frontotemporal dementia (FTD) and Alzheimer's disease (AD) have not been previously investigated together.

Objective

To study anxiety and depression as independent risk factors for FTD and AD.

Methods

Eighty-four patients with FTD and 556 patients with AD were compared with 117 cognitively healthy (CH), elderly individuals. Both cases and controls were participants in the second Health Study of Nord-Trøndelag (HUNT2) from 1995 to 1997, in which depression and anxiety were assessed with the Hospital Anxiety and Depression Scale (HADS).

Results

Significant associations were found between anxiety and FTD and between depression and AD. A significantly increased risk of developing FTD was observed in patients who had reported anxiety on the HADS (p = 0.017) (odds ratio [OR]: 2.947, 95% confidence interval [CI]: 1.209-7.158) and a significantly increased risk of developing AD was observed in patients who had reported depression on the HADS (p = 0.016) (OR: 4.389, 95% CI: 1.311-14.690).

Conclusion

Our study findings suggest that anxiety and depression may play different roles as risk factors for FTD and AD.

Support for midlife anxiety diagnosis as an independent risk factor for dementia: a systematic review

OBJECTIVES

Anxiety is an increasingly recognised predictor of cognitive deterioration in older adults and in those with mild cognitive impairment. Often believed to be a prodromal feature of neurodegenerative disease, anxiety may also be an independent risk factor for dementia, operationally defined here as preceding dementia diagnosis by ≥10 years.

DESIGN

A systematic review of the literature on anxiety diagnosis and long-term risk for dementia was performed following published guidelines.

SETTING AND PARTICIPANTS

Medline, PsycINFO and Embase were searched for peer-reviewed journals until 8 March 2017. Publications reporting HR/OR for all-cause dementia based on clinical criteria from prospective cohort or case-control studies were selected. Included studies measured clinically significant anxiety in isolation or after controlling for symptoms of depression, and reported a mean interval between anxiety assessment and dementia diagnosis of at least 10 years. Methodological quality assessments were performed using the Newcastle-Ottawa Scale.

OUTCOME MEASURE

HR/OR for all-cause dementia.

RESULTS

Searches yielded 3510 articles, of which 4 (0.02%) were eligible. The studies had a combined sample size of 29 819, and all studies found a positive association between clinically significant anxiety and future dementia. Due to the heterogeneity between studies, a meta-analysis was not conducted.

CONCLUSIONS

Clinically significant anxiety in midlife was associated with an increased risk of dementia over an interval of at least 10 years. These findings indicate that anxiety may be a risk factor for late-life dementia, excluding anxiety that is related to prodromal cognitive decline. With increasing focus on identifying modifiable risk factors for dementia, more high-quality prospective studies are required to clarify whether clinical anxiety is a risk factor for dementia, separate from a prodromal symptom.

Anxiety symptoms and risk of dementia and mild cognitive impairment in the oldest old women

OBJECTIVES

Research is limited and findings conflict regarding anxiety as a predictor of future cognitive decline in the oldest old persons. We examined the relationship between levels of and changes in anxiety symptoms, and subsequent dementia and mild cognitive impairment (MCI) in the oldest old women.

METHOD

We conducted secondary analyses of data collected from 1425 community-dwelling women (mean age = 82.8, SD ±3.1 years) followed on average for five years. The Goldberg Anxiety Scale was used to assess anxiety symptoms at baseline, and an expert clinical panel adjudicated dementia and MCI at follow-up. Participants with probable cognitive impairment at baseline were excluded.

RESULTS

At baseline, 190 (13%) women had moderate/severe anxiety symptoms and 403 (28%) had mild anxiety symptoms. Compared with those with no anxiety symptoms at baseline, women with mild anxiety symptoms were more likely to develop dementia at follow-up (multivariable-adjusted odds ratio = 1.66, 95% confidence interval 1.12-2.45). No significant association was observed between anxiety symptoms and MCI.

CONCLUSION

In the oldest old women, our findings suggest that mild anxiety symptoms may predict future risk of dementia, but not MCI. Future studies should explore potential biological mechanisms underlying associations of anxiety with cognitive impairment.

Predicting dementia from primary care records: A systematic review and meta-analysis

INTRODUCTION

Possible dementia is usually identified in primary care by general practitioners (GPs) who refer to specialists for diagnosis. Only two-thirds of dementia cases are currently recorded in primary care, so increasing the proportion of cases diagnosed is a strategic priority for the UK and internationally. Variables in the primary care record may indicate risk of developing dementia, and could be combined in a predictive model to help find patients who are missing a diagnosis. We conducted a meta-analysis to identify clinical entities with potential for use in such a predictive model for dementia in primary care.

METHODS AND FINDINGS

We conducted a systematic search in PubMed, Web of Science and primary care database bibliographies. We included cohort or case-control studies which used routinely collected primary care data, to measure the association between any clinical entity and dementia. Meta-analyses were performed to pool odds ratios. A sensitivity analysis assessed the impact of non-independence of cases between studies. From a sift of 3836 papers, 20 studies, all European, were eligible for inclusion, comprising >1 million patients. 75 clinical entities were assessed as risk factors for all cause dementia, Alzheimer's (AD) and Vascular dementia (VaD). Data included were unexpectedly heterogeneous, and assumptions were made about definitions of clinical entities and timing as these were not all well described. Meta-analysis showed that neuropsychiatric symptoms including depression, anxiety, and seizures, cognitive symptoms, and history of stroke, were positively associated with dementia. Cardiovascular risk factors such as hypertension, heart disease, dyslipidaemia and diabetes were positively associated with VaD and negatively with AD. Sensitivity analyses showed similar results.

CONCLUSIONS

These findings are of potential value in guiding feature selection for a risk prediction tool for dementia in primary care. Limitations include findings being UK-focussed. Further predictive entities ascertainable from primary care data, such as changes in consulting patterns, were absent from the literature and should also be explored in future studies.

Anxiety symptoms and risk of cognitive decline in older community-dwelling men

BACKGROUND

Previous research regarding anxiety as a predictor of future cognitive decline in older adults is limited and inconsistent. We examined the independent relationship between anxiety symptoms and subsequent cognitive decline.

METHODS

We included 2,818 community-dwelling older men (mean age = 76.1, SD ±5.3 years) who were followed on an average for 3.4 years. We assessed anxiety symptoms at baseline using the Goldberg Anxiety Scale (GAS; range = 0-9). We assessed cognitive function at baseline and at two subsequent visits using the Modified Mini-Mental State Examination (3MS; global cognition) and the Trails B test (executive function).

RESULTS

At baseline, there were 690 (24%) men with mild anxiety symptoms (GAS 1-4) and 226 (8%) men with moderate/severe symptoms (GAS 5-9). Men with anxiety symptoms were more likely to have depressed mood, poor sleep, more chronic medical conditions, and more impairment in activities of daily living compared to those with no anxiety symptoms. Compared to those with no anxiety symptoms at baseline, men with any anxiety symptoms were more likely to have substantial worsening in Trails B completion time (OR = 1.56, 95% CI 1.19, 2.05). The association was attenuated after adjusting for potential confounders, including depression and poor sleep, but remained significant (OR = 1.40, 95% CI 1.04, 1.88).

CONCLUSION

In cognitively healthy older men, mild anxiety symptoms may potentially predict future decline in executive functioning. Anxiety is likely a manifestation of an underlying neurodegenerative process rather than a cause.

Affective concordance in couples: a cross-sectional analysis of depression and anxiety consultations within a population of 13,507 couples in primary care

BACKGROUND

Depression and anxiety are common and have a significant impact on the individual and wider society. One theory proposed to explain a heightened risk for depression and anxiety is affective concordance in couples (e.g. influence of shared mood states, shared health beliefs). Whilst research has shown concordance for severe psychiatric illnesses and general mood in couples, little attention has been given to concordance for common psychiatric conditions such as depression and anxiety. The aims of this study were to test affective concordance in couples and examine potential influences on concordance.

METHODS

Study design is a 1-year cross-sectional study of anxiety and depression consultations in primary care. Data were obtained from a validated primary care database of recorded consultations. Outcome was the presence of an anxiety or depression Read Code (GP recorded reason for consultation) in the female (within the couple dyad), and exposure was a recorded Read Code of anxiety or depression in the male. Logistic regression was used to test associations with odds ratios (OR) and 95% confidence intervals (95% CI) reported. Statistical adjustment was carried out on potential influences of concordance; age, environment (deprivation), healthcare behaviour (consultation frequency), and comorbidity.

RESULTS

A population of 13,507 couples were identified in which 927 people consulted for anxiety and 538 for depression. Logistic regression showed a 3 times increase in odds of an anxiety consultation in females if their male partner had also consulted OR 2.98 (95% CI 2.15 to 4.13). For depression females were over 4 times the odds of consulting if their male partner had also consulted OR 4.45 (95% CI 2.79 to 7.09). Adjustment within a multivariable model showed some reduction in odds; concordant anxiety was reduced to 2.5 times odds OR 2.48 (95%CI 1.76 to 3.50) and depression reduced to OR 3.39 (2.07 to 5.54).

CONCLUSION

Results show significant associations for affective concordance in couples. Factors influencing concordance are comorbidity and environmental factors, however reasons for deciding to consult (positive or negative) are unknown. This study highlights the patients' social context as a factor in consultations for anxiety and depression and gives support to the consideration of the patient's household as an influence on mental health.

Temporal dynamics of cognitive performance and anxiety across older adulthood

Cognitive decline and anxiety symptoms commonly co-occur in later life, but the temporal order of changes on these two attributes is unclear. Specifically, it is unknown if greater anxiety leads to subsequent declines in cognitive performance or if worse cognitive performance leads to increased anxiety. In this study, we sought to elucidate the temporal dynamics between anxiety symptoms and cognitive performance across old age-that is, the extent to which level and change in one variable influence subsequent changes in a second variable. We examined data from 721 nondemented participants from the Swedish Adoption/Twin Study of Aging. Participants completed as many as eight assessments of cognitive performance and anxiety over a 26-year period. Bivariate dual-change score models were fit to examine the dynamic association between anxiety and cognitive performance. Bidirectional associations between anxiety and cognitive performance were found among measures of processing speed, attention, and memory but not visuospatial abilities. Higher anxiety was associated with greater declines in processing speed over the duration of 6 years and worsening attention over a span of 3 years. The reverse direction was also significant in that slower processing speed, worse attention, and poorer nonverbal and working memory performance were associated with larger increases in anxiety 3 years later. These findings highlight that in cognitively intact older adults, the association between anxiety and worse cognitive performance is bidirectional and complex. (PsycINFO Database Record

The Roles of Exercise and Yoga in Ameliorating Depression as a Risk Factor for Cognitive Decline

Currently, there are no effective pharmaceutical treatments to reduce cognitive decline or prevent dementia. At the same time, the global population is aging, and rates of dementia and mild cognitive impairment (MCI) are on the rise. As such, there is an increasing interest in complementary and alternative interventions to treat or reduce the risk of cognitive decline. Depression is one potentially modifiable risk factor for cognitive decline and dementia. Notably, exercise and yoga are two interventions known to both reduce symptoms of depression and improve cognitive function. The current review discusses the efficacy of exercise and yoga to ameliorate depression and thereby reduce the risk of cognitive decline and potentially prevent dementia. Potential mechanisms of change, treatment implications, and future directions are discussed.

Anxiety as a Predictor for Cognitive Decline and Dementia: A Systematic Review and Meta-Analysis

BACKGROUND

Because anxiety is postulated as a risk factor for dementia, we performed a systematic review and meta-analysis to investigate whether anxiety predicts cognitive decline and/or dementia, taking the stage of cognitive decline as well as setting into account.

METHODS

A systematic literature search up to January 2015 was performed to identify all longitudinal studies on the association between anxiety and cognition. Data extraction and methodological quality assessment were conducted independently by two authors. Where possible, pooled relative risks were calculated to examine anxiety as a possible risk factor for cognitive decline cognitive impairment and dementia in community studies (objective 1), as well as for conversion to dementia patients referred to memory clinics (objective 2).

RESULTS

Twenty studies met inclusion criteria. Data on cognitive decline were too heterogeneous for meta-analysis. Anxiety predicted incident cognitive impairment (4 studies, relative risk [RR]: 1.77, 95% confidence interval [CI]: 1.38-2.26, z = 4.50, p < 0.001) and dementia (6 studies, RR: 1.57, 95% CI: 1.02-2.42, z = 2.05, p = 0.040) in the community, the latter driven by studies with a mean age of 80 years or above. Among clinical mild cognitive impairment samples, anxiety did not predict conversion to dementia (RR: 1.21, 95% CI: 0.90-1.63, z = 1.28, p = 0.200).

CONCLUSIONS

Anxiety is associated with an increased risk for cognitive impairment and dementia in the community. Stronger associations were driven by higher age, suggesting that it is a prodromal symptom. Causal biological pathways have also been described, which could explain the risk for incident cognitive impairment in the community. Future studies should include mediating mechanism when studying anxiety as a predictor for cognitive decline and/or dementia.

Anxiety is associated with increased risk of dementia in older Swedish twins

INTRODUCTION

We asked whether anxiety is associated with prospective risk of dementia, and the extent to which genetic influences mediate this association.

METHODS

Nondemented twins (n = 1082) from the Swedish Adoption Twin Study of Aging completed an assessment of anxiety symptoms in 1984 and were followed for 28 years.

RESULTS

Baseline anxiety score, independent of depressive symptoms, was significantly associated with incident dementia over follow-up (hazard ratio [HR] = 1.04; 95% confidence interval [CI] = 1.01-1.06). There was 48% increased risk of becoming demented for those who had experienced high anxiety at any time compared with those who had not. In co-twin analyses, the association between anxiety symptoms and dementia was greater for dizygotic (HR = 1.11; 95% CI = 1.02-1.20) compared with monozygotic twins (HR = 1.06; 95% CI = 0.95-1.20), indicating genetic mediation.

DISCUSSION

Anxiety symptoms were associated with increased risk of dementia. Genetic factors common to dementia and anxiety partially mediated this association.

A longitudinal study of anxiety and cognitive decline in dementia with Lewy bodies and Alzheimer's disease

Background

Anxiety in dementia is common but not well studied. We studied the associations of anxiety longitudinally in Alzheimer’s disease (AD) and dementia with Lewy bodies (DLB).

Methods

In total, 194 patients with a first-time diagnosis of dementia were included (n = 122 patients with AD, n = 72 patients with DLB). Caregivers rated the patients’ anxiety using the Neuropsychiatric Inventory, and self-reported anxiety was assessed with the anxiety and tension items on the Montgomery–Åsberg Depression Rating Scale. The Mini Mental State Examination was used to assess cognitive outcome, and the Clinical Dementia Rating (CDR)-Global and CDR boxes were used for dementia severity. Linear mixed effects models were used for longitudinal analysis.

Results

Neither in the total sample nor in AD or DLB was caregiver-rated anxiety significantly associated with cognitive decline or dementia severity over a 4-year period. However, in patients with DLB, self-reported anxiety was associated with a slower cognitive decline than in patients with AD. No support was found for patients with DLB with clinical anxiety having a faster decline than patients with DLB without clinical anxiety. Over the course of 4 years, the level of anxiety declined in DLB and increased in AD.

Conclusions

Anxiety does not seem to be an important factor for the rate of cognitive decline or dementia severity over time in patients with a first-time diagnosis of dementia. Further research into anxiety in dementia is needed.

Treating Anxiety Disorders in Older Adults: Current Treatments and Future Directions

Anxiety disorders are highly prevalent among the elderly and are associated with increased disability, poor quality of life, and cognitive impairment. Despite this high prevalence and associated morbidities, anxiety disorders in late life are underreported and understudied. In this article, we discuss the epidemiology, disease presentation, and current treatment of anxiety disorders in older adults. We also discuss limitations in the current understanding of such disorders in this population, as well as future research directions that may reveal the mechanisms and rationale for treatment regimens for anxiety disorders in late life. We present material on the application of the Research Domain Criteria (RDoC) model to geriatric anxiety. Finally, we describe optimal management strategies of anxiety disorders.

In sickness and in health: A cross-sectional analysis of concordance for musculoskeletal pain in 13,507 couples

Background

Musculoskeletal pain conditions are common and create substantial burden for the individual and society. While research has shown concordance between couples for risk of some diseases, e.g. heart disease or diabetes, little information is available on such effects for musculoskeletal pain conditions. Our aims were to investigate the presence of concordance between couples for consultations about pain, and to examine theoretical influences on such concordance.

Methods

This was a 1‐year cross‐sectional study of musculoskeletal pain consultations in a UK primary care database. In total 27,014 patients (13,507 couples) aged between 30 and 74 years were included. The main outcome measure was the presence of a musculoskeletal morbidity read code indicating a consultation for musculoskeletal conditions (any, back, neck, knee, shoulder, foot, osteoarthritis). Logistic regression was used to test associations with odds ratios (OR) and 95% confidence intervals (95% CI).

Results

Patients whose partner had a musculoskeletal pain consultation were also more likely to consult for a musculoskeletal condition (OR 1.22, 95% CI 1.12–1.32). This association was found to be strongest for shoulder disorders (OR 1.91, 95% CI 1.06–3.47). No significant associations were found for other pain conditions.

Conclusion

Results show that partner concordance is present for consultations for some musculoskeletal conditions but not others. Possible explanations for concordance include the shared health behaviours between couples leading to potential heightened awareness of symptoms. Given the high prevalence of musculoskeletal pain within populations, it may be worth considering further the mechanisms that explain partner concordance.

Presentation of respiratory symptoms prior to diagnosis in general practice: a case-control study examining free text and morbidity codes

OBJECTIVE

General practitioners can record patients' presenting symptoms by using a code or free text. We compared breathlessness and wheeze symptom codes and free text recorded prior to diagnosis of ischaemic heart disease (IHD), chronic obstructive pulmonary disease (COPD) and asthma.

DESIGN

A case-control study.

SETTING

11 general practices in North Staffordshire, UK, contributing to the Consultations in Primary Care Archive consultation database.

PARTICIPANTS

Cases with an incident diagnosis of IHD, COPD or asthma in 2010 were matched to controls (four per case) with no such diagnosis. All prior consultations with codes for breathlessness or wheeze symptoms between 2004 and 2010 were identified. Free text of cases and controls were also searched for mention of these symptoms.

RESULTS

592 cases were identified, 194 (33%) with IHD, 182 (31%) with COPD and 216 (37%) with asthma. 148 (25%) cases and 125 (5%) controls had a prior coded consultation for breathlessness. Prevalence of a prior coded symptom of breathlessness or wheeze was 30% in cases, 6% in controls. Median time from first coded symptom to diagnosis among cases was 57 weeks. After adding symptoms recorded in text, prevalence rose to 62% in cases and 25% in controls. Median time from first recorded symptom increased to 144 weeks. The associations between diagnosis of cases and prior symptom codes was strong IHD relative risk ratio (RRR) 3.21 (2.15 to 4.79); COPD RRR 9.56 (6.74 to 13.60); asthma RRR 10.30 (7.17 to 14.90).

CONCLUSIONS

There is an association between IHD, COPD and asthma diagnosis and earlier consultation for respiratory symptoms. Symptoms are often noted in free text by GPs long before they are coded. Free text searching may aid investigation of early presentation of long-term conditions using GP databases, and may be an important direction for future research.

Anxiety symptoms in amnestic mild cognitive impairment are associated with medial temporal atrophy and predict conversion to Alzheimer disease

OBJECTIVE

To test the hypothesis that anxiety in amnestic mild cognitive impairment (aMCI) increases rates of conversion to Alzheimer disease (AD) and to identify potential neural mechanisms underlying such an association.

METHODS

Participants (N = 376) with aMCI from the Alzheimer's Disease Neuroimaging Initiative (ADNI) were studied over a median period of 36 months. A Cox proportional-hazards model was used to assess the association between anxiety severity ratings on the Neuropsychiatric Inventory Questionnaire and AD risk. Other variables were depression, memory loss, and MRI-derived AD-related regions of interest (ROIs), including hippocampal, amygdalar, entorhinal cortical (EC) volumes, and EC thickness, In addition, a linear regression model was used to determine the effect of anxiety in aMCI on rates of atrophy within ROIs.

RESULTS

Anxiety severity increased rate of aMCI conversion to AD, after controlling for depression and cognitive decline. The association between anxiety and AD remained significant even with inclusion of ROI baseline values or atrophy rates as explanatory variables. Further, anxiety status predicted greater rates of decrease in EC volume. An association between anxiety and EC thickness missed significance.

CONCLUSION

Anxiety symptoms in aMCI predict conversion to AD, over and beyond the effects of depression, memory loss, or atrophy within AD neuroimaging biomarkers. These findings, together with the greater EC atrophy rate predicted by anxiety, are compatible with the hypothesis that anxiety is not a prodromal noncognitive feature of AD but may accelerate decline toward AD through direct or indirect effects on EC.

The synergistic effects of anxiety and cerebral hypoperfusion on cognitive dysfunction in older adults with cardiovascular disease

OBJECTIVES

Anxiety is a risk factor for cardiovascular disease (CVD) and is associated with neurocognitive outcomes. The effect of anxiety on brain perfusion in a CVD population has yet to be examined, and no study has investigated the interactive effects of anxiety and cerebral perfusion on cognition.

METHODS

A total of 55 older adults with CVD completed the Beck Anxiety Inventory (BAI) and underwent arterial spin labeling to quantify cortical perfusion and thickness. Participants were administered the Mini-Mental State Examination (MMSE) and the Repeatable Battery for the Assessment of Neuropsychological Status.

RESULTS

Reduced perfusion predicted poorer cognition and decreased cortical thickness. Higher anxiety score predicted worse memory performance and decreased frontal perfusion. Frontal lobe hypoperfusion combined with increased BAI scores exacerbated poorer MMSE performance.

CONCLUSIONS

Higher anxiety may exacerbate the effects of cerebral hypoperfusion on cognitive impairment. Longitudinal studies are needed to confirm our findings and determine whether anxiety treatment improves neurocognitive outcomes in CVD.

The new DSM-5 diagnosis of mild neurocognitive disorder and its relation to research in mild cognitive impairment

The Diagnostic Statistical Manual-5 (DSM-5) has included a category named the neurocognitive disorder which was formally known in DSM-IV as 'dementia, delirium, amnestic, and other cognitive disorders'. The DSM-5 distinguishes between 'mild' and 'major' neurocognitive disorders. Major neurocognitive disorder replaces the DSM-IV's term 'dementia or other debilitating conditions'. A pivotal addition is 'mild neurocognitive disorder (mNCD)' defined by a noticeable decrement in cognitive functioning that goes beyond normal changes seen in aging. It is a disorder that may progress to dementia - importantly, it may not. Presently, our understanding of mNCD is derived from research on mild cognitive impairment (MCI). Whereas there is currently no clear treatment for mNCD, many experimental therapies now and into the future will focus upon secondary prevention, namely decreasing the risk of progression to major NCD. In this article, we will focus on mNCD by reviewing the relevant literature on MCI. We will review the research on the incidence and prevalence of MCI, conversion rates from MCI to dementia, risk factors for conversion of MCI to dementia, comorbidity of MCI with other neuropsychiatric disorders (NPS), and the development of treatment strategies for neuropsychiatric disorders in MCI. The presence of NPS is common among individuals with MCI and is an important risk for progression to dementia. However, there has been little research on effective treatments for NPS in MCI. Clinicians and investigators must determine if the treatment of the NPS in mNCD will improve quality of life and help reduce the progression of the cognitive impairment.

Anxiety is not associated with the risk of dementia or cognitive decline: the Rotterdam Study

OBJECTIVE

Anxiety and depression frequently co-occur in the elderly and in patients with dementia. Prior research has shown that depression is related to the risk of dementia, but the effect of anxiety on dementia remains unclear. We studied whether anxiety symptoms and anxiety disorders are associated with the risk of dementia and cognition.

METHODS

We studied 2,708 nondemented participants from the prospective, population-based Rotterdam Study who underwent the Hospital Anxiety and Depression Scale (HADS) (sample I, baseline 1993-1995) and 3,069 nondemented participants who underwent screening for anxiety disorders (sample II, baseline 2002-2004). In 1993-1995, anxiety symptoms were assessed using the HADS. In 2002-2004, anxiety disorders were assessed using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. In both study samples, participants were continuously monitored for dementia until January 1, 2011. Cognition was tested in 2002-2004 and at a follow-up visit in 2009-2011 in sample II only.

RESULTS

In sample I, 358 persons developed dementia, and in sample II, 248 persons developed dementia. We did not find an association with the risk of dementia for anxiety symptoms (hazard ratio 1.05, 95% confidence interval: 0.77-1.43, Wald statistic 0.08, p = 0.77, df = 1) or for anxiety disorders (hazard ratio 0.92, 95% confidence interval: 0.58-1.45, Wald statistic 0.14, p = 0.71, df = 1). We could demonstrate an association of anxiety disorders with poor cognition cross-sectionally, but this attenuated after additional adjustments.

CONCLUSION

Our findings do not offer evidence for an association between anxiety symptoms or anxiety disorders with the risk of dementia or with cognition. This suggests that anxiety is not a risk factor nor a prodrome of dementia in an elderly, community-dwelling population.

Cognitive function and associated factors among older people in Taiwan: age and sex differences

PURPOSE

The aim of this study was to examine cognitive function and the risk and the protective factors by age and sex among Taiwanese older people.

METHODS

The data were from a nation-representative panel of older people in Taiwan. The participants completing both the 2003 and 2007 waves were included for analysis in this study (n=3228). Descriptive analysis and generalized linear model were applied, and the samples were stratified by age groups and by sex.

RESULTS

The factors related to higher cognitive function at the intercept included being younger, male, higher education, and doing unpaid work. At the time slope, the age effect and physical function difficulties would reduce the cognitive function across time, while education and providing informational support would increase the cognitive function across time. There were age- and sex-differences in the factors related to cognitive function, particularly on the working status and social participation.

CONCLUSION

Different health promotion strategies to target these populations should be accordingly developed.