12-month cognitive outcomes of major and minor depression in older medical patients

Cognition and Frailty in Patients With Heart Failure: A Systematic Review of the Association Between Frailty and Cognitive Impairment

Background/Aim: Pathological processes associated with aging increase the risk of cognitive deficits. Frailty syndrome may significantly accelerate these pathological processes in elderly patients with heart failure. The objective of this review was to better understand the association between frailty syndrome and co-occurring cognitive decline in patients with heart failure. Methods: We conducted a systematic review based on PubMed/MEDLINE, Scopus, EMBASE, and CINAHL as databases. The search followed the method described by Webb and Roe. For inclusions, the studies were selected employing cross-sectional and longitudinal designs. The included studies had to evaluate frailty syndrome and cognitive impairments among participants with heart failure. As we were interested in older adults, the search was limited to individuals >65 years of age. The search was limited to primary research articles written in English published since the year 2000. Results: Of the 1,245 studies retrieved by the systematic review, 8 relevant studies were enclosed for the full-text review. Our review revealed that most studies of patients with HF demonstrated evidence of an association between greater frailty and cognitive impairment. In particular, six studies reported evidence for the significant association between higher levels of frailty and cognitive impairment in patients with heart failure. The remaining two studies failed to find an association between frailty and cognitive impairment. Conclusions: The development of frailty and cognitive impairment in heart failure is particularly important because this cardiovascular disease is a common cause of both morbidity and mortality in the world. The results of this review fill the existing gap in the literature related to the identification of clinical factors linked with frailty syndrome that contribute to cognitive impairment in patients with a diagnosis of heart failure. The prevalence of overlapping frailty and cognitive impairment in patients with heart failure, therefore, necessitates a routine assessment of these components in the care of patients with cardiovascular disease.

Morbidity and mortality in very old individuals with subsyndromal depression: an 8-year prospective study

OBJECTIVES

Both morbidity and mortality are elevated for individuals with subsyndromal depression (SSD) compared to non-depression (ND) in those of younger ages, but scientific studies are scarce for very old individuals. The aim of this study was therefore to compare the morbidity and mortality in very old individuals with SSD and ND.

DESIGN AND SETTING

An 8-year prospective population-based study was undertaken on 85-year-old individuals in Sweden.

MEASUREMENTS

Data were collected from postal questionnaires and clinical assessments at baseline, after 1, 5, and 8 years. Depressive symptoms were measured with Geriatric Depression Scale and the results were classified into ND, SSD, and syndromal depression. Mortality was investigated using multivariable cox regressions, and variables of morbidity were investigated using linear mixed models.

RESULTS

Compared to ND, in people with SSD, mortality was elevated in the univariate regression, but this association vanished when controlling for relevant covariates. Morbidity was elevated with regard to basic activities of daily living (ADLs), instrumental ADLs, loneliness, self-perceived health, and depressive symptoms for individuals with SSD compared to ND, whereas cognitive speed, executive functions, and global cognitive function were not significantly impaired when adjusting for covariates.

CONCLUSIONS

SSD among very old individuals is longitudinally associated with elevated morbidity but not mortality, when controlling for relevant covariates. Considering the high prevalence of SSD and the demographic development of increasing numbers of very old people, the findings highlight the need to develop clinical and societal strategies to prevent SSD and associated negative outcomes.

Affective problems and decline in cognitive state in older adults: a systematic review and meta-analysis

Evidence suggests that affective problems, such as depression and anxiety, increase risk for late-life dementia. However, the extent to which affective problems influence cognitive decline, even many years prior to clinical diagnosis of dementia, is not clear. The present study systematically reviews and synthesises the evidence for the association between affective problems and decline in cognitive state (i.e., decline in non-specific cognitive function) in older adults. An electronic search of PubMed, PsycInfo, Cochrane, and ScienceDirect was conducted to identify studies of the association between depression and anxiety separately and decline in cognitive state. Key inclusion criteria were prospective, longitudinal designs with a minimum follow-up period of 1 year. Data extraction and methodological quality assessment using the STROBE checklist were conducted independently by two raters. A total of 34 studies (n = 71 244) met eligibility criteria, with 32 studies measuring depression (n = 68 793), and five measuring anxiety (n = 4698). A multi-level meta-analysis revealed that depression assessed as a binary predictor (OR 1.36, 95% CI 1.05-1.76, p = 0.02) or a continuous predictor (B = -0.008, 95% CI -0.015 to -0.002, p = 0.012; OR 0.992, 95% CI 0.985-0.998) was significantly associated with decline in cognitive state. The number of anxiety studies was insufficient for meta-analysis, and they are described in a narrative review. Results of the present study improve current understanding of the temporal nature of the association between affective problems and decline in cognitive state. They also suggest that cognitive function may need to be monitored closely in individuals with affective disorders, as these individuals may be at particular risk of greater cognitive decline.

Subthreshold Depression Needs A Prime Time In Old Age Psychiatry? A Narrative Review Of Current Evidence

This study aims to carry out a narrative review, aiming to update the literature on subsyndromic depression (SD), which is the most prevalent depressive disorder in older adults, and no formal guidelines or consensus are dedicated to this topic. We carried out an electronic search for articles on SD. Relevant articles were retrieved from Pubmed, EMBASE and Web of Science using the search terms "subthreshold depression," "prevalence," "treatment" and "older adults" in several combinations. Original articles in English were included from inception to 1st March 2019. No clear consensus exists in the literature on its nosologic classification, diagnostic tools, causes, course, outcomes or management. SD diagnosis should base in depressive symptoms scales and DSM criteria. Treatment relies mainly on collaborative care and psychotherapy. SD is relevant in clinical practice and research in geriatric psychiatry. Given the negative outcomes and potential benefits of treatment, we recommend brief psychotherapy as first-line treatment and use of psychotropic agents in cases with greater severity and/or functional impairment in association with psychotherapy. SD can precede major depressive disorder, but it also may consist of a primary depressive disorder in older adults. Furthermore, adequate treatment of SD can prevent or reduce negative outcomes associated with depressive symptoms such as worsening of clinical comorbidities, loss of functionality, increased demand for health services, and increased mortality.

The Association Between Midlife Physical Activity and Depressive Symptoms in Late Life: Age Gene/Environment Susceptibility-Reykjavik Study

BACKGROUND

There is little evidence on the long-term association between physical activity (PA) and depressive symptoms in old age. We examined the association of midlife PA and depressive symptoms in late life.

METHODS

A large community-based population residing in Reykjavik, Iceland, participated in a longitudinal study with an average of 25 years of follow up. Midlife PA was categorized as active and inactive groups (n = 4,140, Active = 1,292, Inactive = 2,848, mean age 52±7 years). The main outcome had six or higher depressive symptoms assessed by the 15-item Geriatric Depression scale. Participants who had a history of depression (n = 226), and were diagnosed with dementia (n = 393), and had incomplete cognitive data (n = 595) and incomplete analytical data (n = 422) were excluded. Level of weekly PA was ascertained by a questionnaire at midlife. Depressive symptoms were assessed on average 25 (±4) years later.

RESULTS

After controlling for demographic and health-related risk factors, those who were active at midlife were less likely to have high level of depressive symptomatology (6 or higher Geriatric Depression scale scores, odds ratio = 0.58, 95% confidence interval: 0.41-0.83, p < .005) compared with those who were inactive in midlife. After full adjustment of three domains of late-life cognitive function the results remained significant (odds ratio = 0.61, 95% confidence interval: 0.43-0.86, p = .005).

CONCLUSION

Our study shows that midlife PA is associated with lower depressive symptoms 25 years later. Participating in regular PA in midlife may improve mental health in late life.

Depressive Symptoms Affect Working Memory in Healthy Older Adult Hispanics

OBJECTIVES

Low and middle income nations will experience an unprecedented growth of the elderly population and subsequent increase in age-related neurological disorders. Worldwide prevalence and incidence of all-types of neurological disorders with serious mental health complications will increase with life expectancy across the globe. One-in- ten individuals over 75 has at least moderate cognitive impairment. Prevalence of cognitive impairment doubles every 5 years thereafter. Latin America's population of older adult's 65 years and older is growing rapidly, yet little is known about cognitive aging among healthy older Latinos. Clinically significant depressive symptomatology is common among community-dwelling older adults and is associated with deficits across multiple cognitive domains, however much of the literature has not modeled the unique effects of depression distinct from negative and low positive affect. Our objective was to understand how mental health affects cognitive health in healthy aging Latinos.

METHODS

The present study used confirmatory factor analysis (CFA) and structural equation modeling (SEM) to examine the relative effects of Negative Affect, Positive Affect and Geriatric Depression on Verbal Memory, Verbal Reasoning, Processing Speed, and Working Memory in healthy aging Latinos. Data was collected from a sample of healthy community dwelling older adults living in San Jose, Costa Rica. Modeling of latent variables attenuated error and improved measurement reliability of cognition, affect, and depression variables.

RESULTS

Costa Ricans enjoy a notoriety for being much happier than US citizens and are renowned as one of the happiest nations in the world in global surveys. This was born out in these data. Costa Rican affective profiles differed substantively from US profiles. Levels of negative affect and depression were similar to US samples, but their levels of positive affect were much higher. Cognitive performance of these Costa Rican older adults was similar to US-age and education matched peers. CFA and SEM found that increased depressive symptomatology had deleterious effects on Working Memory made up of subtest scores sampling simple attention and vigilance for numbers. Verbal Memory, Verbal Reasoning, and Processing Speed were not affected by self-reported Positive Affect, Negative Affect or Depressive symptoms.

CONCLUSION

Costa Rican older adults were happy, as evidenced by the high ratio of positive affect to relatively low negative affect. Thus, we were somewhat surprised to find that depressive symptoms were selectively correlated to decrements in working memory and that negative and positive affect contributed negligible amounts of variance to any of the cognitive factors. Because of the methodological rigor of latent variable analysis, these results are very specific. The Working Memory factor is not contaminated with Speed of Processing or other measured cognitive factors. Likewise, the measured Geriatric Depression represents symptoms that are richly cognitive, not overtly affective.

A patient-centered research agenda for the care of the acutely ill older patient

Hospitalists and others acute-care providers are limited by gaps in evidence addressing the needs of the acutely ill older adult population. The Society of Hospital Medicine sponsored the Acute Care of Older Patients Priority Setting Partnership to develop a research agenda focused on bridging this gap. Informed by the Patient-Centered Outcomes Research Institute framework for identification and prioritization of research areas, we adapted a methodology developed by the James Lind Alliance to engage diverse stakeholders in the research agenda setting process. The work of the Partnership proceeded through 4 steps: convening, consulting, collating, and prioritizing. First, the steering committee convened a partnership of 18 stakeholder organizations in May 2013. Next, stakeholder organizations surveyed members to identify important unanswered questions in the acute care of older persons, receiving 1299 responses from 580 individuals. Finally, an extensive and structured process of collation and prioritization resulted in a final list of 10 research questions in the following areas: advanced-care planning, care transitions, delirium, dementia, depression, medications, models of care, physical function, surgery, and training. With the changing demographics of the hospitalized population, a workforce with limited geriatrics training, and gaps in evidence to inform clinical decision making for acutely ill older patients, the identified research questions deserve the highest priority in directing future research efforts to improve care for the older hospitalized patient and enrich training.

Investigation of the effects of solid lipid curcumin on cognition and mood in a healthy older population

Curcumin possesses many properties which may prevent or ameliorate pathological processes underlying age-related cognitive decline, dementia or mood disorders. These benefits in preclinical studies have not been established in humans. This randomized, double-blind, placebo-controlled trial examined the acute (1 and 3 h after a single dose), chronic (4 weeks) and acute-on-chronic (1 and 3 h after single dose following chronic treatment) effects of solid lipid curcumin formulation (400 mg as Longvida®) on cognitive function, mood and blood biomarkers in 60 healthy adults aged 60-85. One hour after administration curcumin significantly improved performance on sustained attention and working memory tasks, compared with placebo. Working memory and mood (general fatigue and change in state calmness, contentedness and fatigue induced by psychological stress) were significantly better following chronic treatment. A significant acute-on-chronic treatment effect on alertness and contentedness was also observed. Curcumin was associated with significantly reduced total and LDL cholesterol and had no effect on hematological safety measures. To our knowledge this is the first study to examine the effects of curcumin on cognition and mood in a healthy older population or to examine any acute behavioral effects in humans. Results highlight the need for further investigation of the potential psychological and cognitive benefits of curcumin in an older population.

Hospitalization and cognitive decline: Can the nature of the relationship be deciphered?

BACKGROUND

Evidence for a relationship between hospitalization and incident cognitive decline exists mainly in the literature focusing on critical care hospitalization. Recent studies, however, have also found an association between noncritical care hospitalization and the development of cognitive decline.

OBJECTIVE

This article will review the literature pertaining to hospitalization and cognitive decline, including hospitalizations for both critical and noncritical care, and in medical and surgical patients. The article will also explore the various factors that have been implicated in the development of cognitive decline and dementia.

METHODS

Review of the literature was completed using PubMed and Medline search programs.

RESULTS

Several articles supporting evidence for the association between hospitalization and cognitive decline are available. Evidence for potential mediating factors also does exist.

CONCLUSIONS

There is evidence to support an association between hospitalization and development of cognitive decline. Factors that could mediate this association include, but may not be limited to, delirium, medications, stress, and depression. There is a need for further research in this area in order to better understand the underlying pathophysiology involved in the development of cognitive decline and dementia and to determine if preventive measures might be beneficial in decreasing risk for cognitive decline for patients who are hospitalized.

Prevalence of minor depression in elderly persons with and without mild cognitive impairment: a systematic review

BACKGROUND

Minor depression (MinD) and mild cognitive impairment (MCI) are common disorders in late life that often coexist. The aim of the present review is to demonstrate prevalence rates of minor depression in older patients with and without MCI.

METHODS

Electronic database searches were performed through Medline, ISI Web of Knowledge, Psycinfo, and Cochrane library. Two independent reviewers extracted the original studies based on inclusion criteria: representative study population aged 55 and older, diagnostics of MinD according to DSM. Data on prevalence rates, risk factors, comorbidity and health care usage were analyzed.

RESULTS

Point prevalence for MinD is higher in medical settings (median 14.4%) than in the community-based settings (median 10.4%) and primary care patients (median 7.7%). Although minor depression is rarely investigated in elderly persons with MCI, nearly 20% of patients with MCI seem to suffer from MinD. No data was found on the prevalence of MCI in patients with MinD. Risk factors associated with MinD include female gender, history of cerebrovascular diseases, generalized anxiety disorder, loneliness, and long-term institutional care.

LIMITATIONS

Methodological differences of included studies resulted in a broad range of prevalence rates. No data is shown regarding the prevalence of MCI in MinD group due to insufficient evidence.

CONCLUSIONS

Our review indicates that MinD is frequent in elderly population. MCI among those subjects has not been sufficiently investigated. Future studies based on clinical structured interviews should be performed in longitudinal design in order to differentiate late-life depression from progressive MCI or early manifestation of Alzheimer's disease.

Cognitive decline one year after hospitalization in older adults without dementia

BACKGROUND/AIMS

We studied cognitive functioning 1 year after hospitalization (T2) in patients at least 65 years old without cognitive impairment at baseline (T1).

METHODS

Cognition was assessed using the Mini-Mental State Examination (MMSE) at both time points. We included 211 (114 women) patients with a mean age of 78.3 (SD 7.0) years and an MMSE score of 24 and above.

RESULTS

At T2, 69 (32.7%) patients had an MMSE score below 24. In participants with MMSE 24-26 at T1, cognitive decline was related to impaired physical self-maintenance, a decline in the performance of the instrumental activities of daily living, impaired hearing and less reading ability. In participants with MMSE 27-30, cognitive decline was associated with higher comorbidity (Charlson Index) and impaired physical self-maintenance and hearing.

CONCLUSION

A reduced functioning level and increased comorbidity predicted a decline in cognitive functioning.

Generalized anxiety disorder, subthreshold anxiety and anxiety symptoms in primary headache

AIMS

The aim of the present study was to evaluate the association between generalized anxiety disorder, subthreshold anxiety (SubAnx) and anxiety symptoms in the prevalence of primary headache.

METHODS

This cross-sectional study evaluated 383 people from a Brazilian low-income community. One-year prevalence rates of migraine, chronic migraine and tension-type headache were calculated. Anxiety symptoms were then separated into the following groups (based on DSM-IV criteria): no anxiety criteria; one anxiety criterion; two anxiety criteria; and generalized anxiety disorder (GAD). The control group (no headaches) was compared with headache sufferers for each anxiety group using an adjusted model controlled for confounding factors.

RESULTS

GAD was present in 37.0% of participants and SubAnx in 16.6%. Those with SubAnx had a 2.28-fold increased chance of having migraine; 3.83-fold increased chance of having chronic migraine, a 5.94-fold increased chance of having tension-type headache and a 3.27-fold increased chance of having overall headache. Some anxiety criteria (irritability, difficulty with sleep, concentration problems, muscle tension and fatigue) had similar prevalence to International Classification of Headache Disorders (ICHD-II) headache criteria such as unilateral pain and nausea for migraine and chronic migraine.

CONCLUSION

Headache sufferers seem to have a high prevalence of anxiety symptoms and SubAnx. In addition, the presence of two or more anxiety criteria (not necessarily fulfilling all the criteria for GAD) was associated with having a headache disorder.

Subthreshold depression in older subjects: an unmet therapeutic need

Major depression, defined according to DSM IV TR criteria, is less common in older subjects, while other types of depression are two to three times more prevalent. This heterogeneous group of disturbances has received different names: depression not otherwise specified, minor depression, subthreshold or subsyndromal depression. Moreover, each condition has been defined using heterogeneous criteria by different authors. The term of subthreshold depression will be adopted in this position statement. Subthreshold depression has been associated with the same negative consequences of major depression, including reduced well being and quality of life, worsening health status, greater disability, increased morbidity and mortality. Nevertheless, there is a dearth of clinical trials in this area, and therefore older patients with subthreshold depression are either not treated or they are treated with the same non pharmacological and pharmacological therapies used for major depression, despite the lack of supporting scientific evidence. There is an urgent need to reach a consensus concerning the diagnostic criteria for subthreshold depression as well as to perform clinical trials to identify effective and safe therapies in this too long neglected patient group.

Molecular neuropathogenesis of Alzheimer's disease: an interaction model stressing the central role of oxidative stress

Alzheimer's disease (AD) exhibits a complex etiology that simultaneously manifests as a complex cellular, neurobiological, molecular, anatomic-physiological and clinical entity. Other significant psychiatric conditions, such as depression and schizophrenia, may also present with complex and concurrent clinical and/or molecular phenotypes. These neuropsychiatric pathologies also originate from both environmental and genetic factors. We analyzed the molecular phenotypes of AD and discuss them with respect to the classical theories, which we integrated into mechanisms that share molecular and/or anatomical connections. Based on these mechanisms, we propose an interaction model and discuss the model in light of studies that refute or support it. Given the spectrum of AD phenotypes, we limit the scope of our discussion to a few, which facilitates concrete analysis. In addition, the study of specific, individual pathogenic phenotypes may be critical to defining the complex mechanisms leading to AD, thereby improving strategies for developing novel therapies.

Antidepressant use and cognitive deficits in older men: addressing confounding by indications with different methods

PURPOSE

Antidepressant use has been associated with cognitive impairment in older persons. We sought to examine whether this association might reflect an indication bias.

METHODS

A total of 544 community-dwelling hypertensive men aged ≥65 years completed the Hopkins Verbal Learning Test at baseline and 1 year. Antidepressant medications were ascertained by the use of medical records. Potential confounding by indications was examined by adjusting for depression-related diagnoses and severity of depression symptoms using multiple linear regression, a propensity score, and a structural equation model (SEM).

RESULTS

Before adjusting for the indications, a one unit cumulative exposure to antidepressants was associated with -1.00 (95% confidence interval [CI], -1.94, -0.06) point lower HVLT score. After adjusting for the indications using multiple linear regression or a propensity score, the association diminished to -0.48 (95% CI, -0.62, 1.58) and -0.58 (95% CI, -0.60, 1.58), respectively. The most clinical interpretable empirical SEM with adequate fit involves both direct and indirect paths of the two indications. Depression-related diagnoses and depression symptoms significantly predict antidepressant use (p < .05). Their total standardized path coefficients on Hopkins Verbal Learning Test score were twice (0.073) or as large (0.034) as the antidepressant use (0.035).

CONCLUSION

The apparent association between antidepressant use and memory deficit in older persons may be confounded by indications. SEM offers a heuristic empirical method for examining confounding by indications but not quantitatively superior bias reduction compared with conventional methods.

Antidepressant use and cognitive functioning in older medical patients with major or minor depression: a prospective cohort study with database linkage

OBJECTIVE

The long-term cognitive effect of antidepressant medications in older persons is not well understood, especially in those with minor depression and complex medical conditions. The objective of this study is to examine this relationship in older medical patients with different depression diagnoses.

METHODS

281 medical inpatients aged 65 years and older from 2 acute care hospitals in Montreal, Canada, were diagnosed as with major or minor depression or without depression according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. They were followed up with the Mini-Mental State Examination for cognitive function and the Hamilton Depression Rating Scale for depressive symptoms at baseline and 3, 6, and 12 months after discharge. Antidepressant medication was ascertained from a provincial prescription database and quantified as cumulative exposures over each follow-up interval.

RESULTS

During the 12-month follow-up period, 1027 antidepressant prescriptions were filled. The most frequently prescribed antidepressant agents were citalopram (0.81 prescriptions per person), sertraline (0.76), and paroxetine (0.66). Antidepressant use was not associated with cognitive changes among patients with major depression or without depression but was associated with an increased Mini-Mental State Examination score in patients with minor depression (1.4 points; 95% confidence interval, 0.1-2.6), independent of change in the severity of depression symptoms, concomitant benzodiazepine or psychotropic drug use, and other potentially important confounders.

CONCLUSIONS

In this cohort of older medical patients, antidepressant use for 12 months did not lead to significant cognitive impairment. The small cognitive improvement among minor depression associated with antidepressant use deserves further investigation.

A tune in "a minor" can "b major": a review of epidemiology, illness course, and public health implications of subthreshold depression in older adults

BACKGROUND

With emphasis on dimensional aspects of psychopathology in development of the upcoming DSM-V, we systematically review data on epidemiology, illness course, risk factors for, and consequences of late-life depressive syndromes not meeting DSM-IV-TR criteria for major depression or dysthymia. We termed these syndromes subthreshold depression, including minor depression and subsyndromal depression.

METHODS

We searched PubMed (1980-Jan 2010) using the terms: subsyndromal depression, subthreshold depression, and minor depression in combination with elderly, geriatric, older adult, and late-life. Data were extracted from 181 studies of late-life subthreshold depression.

RESULTS

In older adults subthreshold depression was generally at least 2-3 times more prevalent (median community point prevalence 9.8%) than major depression. Prevalence of subthreshold depression was lower in community settings versus primary care and highest in long-term care settings. Approximately 8-10% of older persons with subthreshold depression developed major depression per year. The course of late-life subthreshold depression was more favorable than that of late-life major depression, but far from benign, with a median remission rate to non-depressed status of only 27% after ≥1 year. Prominent risk factors included female gender, medical burden, disability, and low social support; consequences included increased disability, greater healthcare utilization, and increased suicidal ideation.

LIMITATIONS

Heterogeneity of the data, especially related to definitions of subthreshold depression limit our ability to conduct meta-analysis.

CONCLUSIONS

The high prevalence and associated adverse health outcomes of late-life subthreshold depression indicate the major public health significance of this condition and suggest a need for further research on its neurobiology and treatment. Such efforts could potentially lead to prevention of considerable morbidity for the growing number of older adults.

Prevalence of major depressive disorder and minor depressive disorder in an elderly Korean population: results from the Korean Longitudinal Study on Health and Aging (KLoSHA)

OBJECTIVE

We investigated the prevalence, risk factors and impact of major depressive disorder (MDD) and minor depressive disorder (MnDD) in a randomly selected community-dwelling Korean elderly population.

METHOD

This study was conducted as a part of the Korean Longitudinal Study on Health and Aging (KLoSHA). A study population of 1118 Korean elders was randomly sampled from residents of Seongnam, Korea aged 65 years or older. Standardized face-to-face interviews and neurological and physical examinations were conducted on 714 respondents using the Korean version of Mini International Neuropsychiatric Interview. MDD was diagnosed according to the DSM-IV criteria, and MnDD according to research criteria proposed in Appendix B of the DSM-IV criteria.

RESULTS

Age-, gender- and education-standardized prevalence rates in Korean elders aged 65 years or older were estimated as 5.37% (95% CI=3.72-7.03) for MDD, 5.52% (95% CI=3.84-7.19) for MnDD, and 10.89% (95% CI=8.60-13.17) for overall late-life depression (LLD). A prior MDD episode (OR=3.07, 95% CI=1.38-6.82 in MDD, OR=3.44, 95% CI=1.49-7.94 in MnDD), female gender (OR=3.55, 95% CI=1.53-8.24 in MDD, OR=2.68, 95% CI=1.19-6.04 in MnDD) and history of stroke or TIA (OR=3.45, 95% CI=1.62-7.35 in MDD, OR=2.95, 95% CI=1.34-6.52 in MnDD) were associated with the risks of both MDD and MnDD. Lack of formal education (OR=2.75, 95% CI=1.30-5.85) and low income (OR=2.83, 95% CI=1.02-7.88) were associated with the risk of MDD only. Quality of life (QOL) of the MDD and MnDD patients was worse than that of non-depressed elders (P<0.001, ANOVA).

CONCLUSION

MnDD was as prevalent as MDD in Korean elders and impacted QOL as MDD did. MnDD patients may increase in the future with accelerated population aging and westernization of lifestyle in Korea.

The death knoll for the MMSE: has it outlived its purpose?

The Mini-Mental State Examination (MMSE) is arguably the best-known cognitive screen in the world. Originally designed to assess cognitive impairment in elderly populations, it has become one of the first steps toward a dementia diagnosis. Routinely used in the clinic and in research internationally, the MMSE, despite its flaws, has managed to retain its popularity for more than 30 years. This review explores when and how the test is used, lists its advantages and disadvantages, and ultimately questions its value. The specific issue that is addressed here is whether the test has outlived its original purpose. The conclusion is that although the MMSE may be a useful tool in many circumstances where a cognitive screen is required, practitioners should be wary of using MMSE total scores as a shortcut toward a dementia diagnosis.

Predictors of preventable nursing home hospitalizations: the role of mental disorders and dementia

OBJECTIVES

Nursing home (NH) hospitalizations place an enormous economic burden on an already overtaxed American healthcare system. Hospitalizations for "ambulatory care-sensitive" (ACS) conditions are considered preventable, as these are physical health conditions that can potentially be treated safely in a NH. The authors examined risk factors, including mental disorders and dementia, for hospitalization of Medicaid-enrolled NH residents with ACS conditions during fiscal year 2003-2006.

METHODS

The authors merged Medicaid claims and enrollment data and Online Survey Certification and Reporting information for 72,251 Medicaid-enrolled NH residents in 647 NHs in Florida. The authors identified at least one ACS hospitalization in 8,382 residents for a total of 10,091 hospital admissions (18.5% of all hospitalizations). The authors used Cox proportional hazard regression to assess time to the first ACS hospitalization.

RESULTS

In a fully adjusted model, younger age, non-white race, dementia, and serious mental disorder were associated with greater risk of ACS hospitalization. In addition, residents with a diagnosed mental disorder and no dementia incurred relatively high expenditures for ACS hospitalizations. Among facility characteristics, participants from for-profit facilities, facilities that were not a member of a chain, had more Medicaid recipients, and fewer than 120 beds had greater risk of ACS hospitalizations.

CONCLUSIONS

Attention to the identified predictors of hospitalization for ACS conditions, which are potentially preventable, could reduce the risk and cost of these hospitalizations among Medicaid-enrolled NH residents. The need to reduce unnecessary hospitalization will become only more urgent as the population ages and healthcare expenses continue to escalate.

The association between serum cortisol and cognitive decline in older persons

OBJECTIVE

To investigate whether serum cortisol levels are associated with cognitive performance and cognitive decline in elderly persons and whether this association differs by age, sex, and depression status.

DESIGN

Data from the Longitudinal Aging Study Amsterdam, with repeated measurements of cognitive performance after 3 and 6 years.

PARTICIPANTS

A total of 1,154 persons, aged 65-88 years.

MEASUREMENTS

Serum concentrations of total cortisol (CRT) and corticosteroid binding globulin (CBG) were measured at baseline, and from these free cortisol index (CRT/CBG) was computed. At baseline and 3 and 6 years of follow-up, global cognitive functioning, verbal memory performance, and speed of information processing were assessed.

RESULTS

After adjustment for demographics, health, and life style variables, a significant association between high levels of free cortisol and poorer performance on verbal learning (B = -0.32; 95% confidence interval: -0.64 to -0.01) was found in both women and men. Additional adjustment for depression did not change this association. In women, but not in men, high levels of free cortisol (B = -0.85; 95% confidence interval: -1.40 to -0.31) were associated with slower speed of information processing. The associations between cortisol and cognitive performance were the same for the younger and the older old and for depressed and nondepressed persons. Higher levels of cortisol were not associated with cognitive decline over a period of 6 years.

CONCLUSION

Our study provides further evidence that high levels of cortisol measured during the day are associated with lower memory function and speed of information processing but not with decline in cognitive functioning over 6 years of time.

A multiplicity of approaches to characterize geriatric depression and its outcomes

PURPOSE OF REVIEW

Research in geriatric depression has always had a multidisciplinary bent, particularly in methods used to characterize depression. Understanding diagnosis, psychiatric comorbidities, and course continues to be a goal of clinical researchers. Those interested in cognitive neuroscience and basic neuroscience have more recently trained their sights on late-life depression. This review identifies recent progress in the characterization of geriatric depression using a variety of methodologies.

RECENT FINDINGS

Depression in the elderly remains underdetected and underdiagnosed, particularly in nonmental health settings. Studies of the impact of psychiatric comorbidities and of the negative outcomes of depression in older adults demonstrate that geriatric depression is a serious medical condition that not only affects mood but can also lead to functional and cognitive decline. Advances in neuroimaging technology have demonstrated structural and functional changes in the brains of older depressed patients. With the advent of brain banks in neuropsychiatry, we are now seeing postmortem neuroanatomical studies that seek to extend findings from clinical practice and from neuroimaging research.

SUMMARY

Clinicians should become more aware of advances in detection of depression, the effect of psychiatric comorbidities, the poor mood and cognitive outcomes associated with late-life depression and should keep abreast of recent neuroimaging and neuroanatomical findings.