Depression-dementia medius: between depression and the manifestation of dementia symptoms

Bifrontal electroconvulsive therapy leads to improvement of cerebral glucose hypometabolism in frontotemporal dementia with comorbid psychotic depression - a case report

BACKGROUND

Differentiating depression and dementia in elderly patients represents a major clinical challenge for psychiatrists. Pharmacological and non-pharmacological treatment options for both conditions are often used cautiously due to fear of adverse effects. If a clinically indicated therapy is not initiated due to fear of adverse effects, the quality of life of affected patients may significantly be reduced.

CASE PRESENTATION

Here, we describe the case of a 65-year-old woman who presented to the department of psychiatry of a university hospital with depressed mood, pronounced anxiety, and nihilistic thoughts. While several pharmacological treatments remained without clinical response, further behavioral observation in conjunction with ¹⁸F-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) revealed the diagnosis of frontotemporal dementia (FTD). To counter the pharmacological treatment resistance of psychotic depression, we decided to perform electroconvulsive therapy (ECT). Remarkably, ten sessions of ECT yielded an almost complete remission of depressive symptoms. In addition, the patient's delusional ideas disappeared. A follow-up ¹⁸F-FDG PET/CT after the ECT series still showed a frontally and parieto-temporally accentuated hypometabolism, albeit with a clear regression compared to the previous image. The follow-up ¹⁸F-FDG PET/CT thus corroborated the diagnosis of FTD, while on the other hand it demonstrated the success of ECT.

CONCLUSIONS

In this case, ECT was a beneficial treatment option for depressive symptoms in FTD. Also, ¹⁸F-FDG PET/CT should be discussed as a valuable tool in differentiating depression and dementia and as an indicator of treatment response.

Association of subclinical depressive symptoms and sleep with cognition in the community-dwelling older adults

BACKGROUND

/Purpose: This study aimed to explore the association of subclinical depressive symptoms and sleep with cognition in community-dwelling Taiwanese older adults.

METHODS

This four-year prospective cohort study (2015-2019) included 379 participants aged 65 years or older from the annual senior health checkup program at National Taiwan University Hospital who were followed up two years later. Global and domain cognitive functions were assessed using validated neuropsychological tests. Depressive symptoms were evaluated using the Center for Epidemiologic Studies Depression (CES-D) Scale. Sleep quality was evaluated using the Pittsburg Sleep Quality Index (PSQI). Excessive daytime sleepiness was assessed using the Epworth Sleepiness Scale (ESS). Generalized linear mixed models were used to explore the associations of subclinical depressive symptoms and sleep variables with cognition, adjusting for important covariates. Stratification analyses were performed using the sleep variables.

RESULTS

Over time, depressive symptoms were associated with poor performance of memory (βˆ = 0.24, P = 0.04) and executive function (βˆ = -0.24, P = 0.03). Poor sleep quality (elevated PSQI score) was associated with poor memory performance (βˆ = -0.04 to -0.03, P < 0.05). Excessive daytime sleepiness (elevated ESS score) was associated with poor performance of memory (βˆ = -0.02, P < 0.05) and executive function (βˆ = -0.02, P = 0.001). At baseline, better sleep quality and no excessive daytime sleepiness were associated with better memory performance over time.

CONCLUSION

Subclinical depressive symptoms, worse sleep quality, and excessive daytime sleepiness were differentially associated with impairment of cognitive domains (mainly memory and executive function).

Cognitive profiles in persons with depressive disorder and Alzheimer's disease

Alzheimer’s disease and depressive disorder are frequent in old age. Both may be associated with depressed mood and cognitive impairment. Therefore, finding a strategy to clarify the diagnosis underlying subjective complaints of impaired cognition and depressed mood in older persons is of utmost interest. We conducted a cross-sectional retrospective observational clinical cohort study using patient records from 2014 to 2018. From 3758 patients, we included patients aged 60 years and older with a Mini-Mental-Status Examination score of 24 and above. Final analysis included all patients in whom Alzheimer’s disease biomarker analysis was performed (cerebrospinal fluid markers of Alzheimer’s disease or positron emission tomography imaging; n = 179) and patients with depressive disorder in whom Alzheimer’s disease was ruled out by analysis of biomarkers suggestive of Alzheimer’s disease (n = 70). With case–control matching for age, education and gender, performance of patients with Alzheimer’s disease was worse in acquisition, consolidation and recall of verbal information and false-positive answers. None of the results, however, sufficed to differentially diagnose individual patients with Alzheimer’s disease or depressive disorder. With more severe symptoms of depression, patients with biomarker-verified Alzheimer’s disease performed worse in executive testing but were not additionally impaired in verbal episodic memory performance. We conclude that distinguishing between Alzheimer’s disease and depressive disorder is unreliable on clinical grounds and behavioural testing alone. Diagnosing the cause of subjective complaints about deteriorating cognitive function or depressed mood requires additional biomarker assessment, whereas cognitive assessment is needed to define appropriate targets of symptomatic treatment in patients with Alzheimer’s disease and depressive disorder.

Similarities Between Depression and Neurodegenerative Diseases: Pathophysiology, Challenges in Diagnosis and Treatment Options

Depressive disorder and neurodegenerative diseases are two different clinical entities. Depression is a common psychiatric disorder in the general population. However, when present concomitantly with neurodegenerative disorders, its diagnosis becomes challenging. In many cases, patients remain undiagnosed and hence, untreated, worsening the prognosis of the neurodegenerative diseases and impairing the quality of life. One of the possible reasons for the difficulties in diagnosis in such cases is that both conditions affect the central nervous system, so there might be an overlap of symptoms leading to a missed diagnosis of depression in a neurodegenerative disease patient and vice versa. Symptoms such as irritability, apathy, and decreased cognition are common to both types of disorders. Some neurodegenerative diseases, especially Alzheimer's disease, can initially present as a depressive prodrome. This may cause a difficulty in differentiating between these two conditions and a diagnosis of either conditions may be missed; hence an opportunity for timely intervention and improved outcomes is missed. An approach towards analyzing and comparing the pathological mechanisms common to both disease types will create a better understanding of depression and neurodegenerative diseases, identify their similarities, and develop improved clinical criteria to help clinicians make a timely diagnosis of these conditions present together. In the present review, various studies related to common pathological links, concomitant diagnosis challenges, and ongoing research about different treatment options are discussed.

Depression is a major risk factor for the development of dementia in people with lower urinary tract symptoms: A nationwide population-based study

Background/Objectives

Studies have shown a strong relationship between depression and dementia. Lower urinary tract symptoms (LUTS) were reported to be independently associated with depression and dementia. However, the relationship between depression and cognitive dysfunction in patients with LUTS is not well characterized.

Method

We conducted a matched cohort study by using a one-million population-based dataset in Taiwan. A total of 15,944 patients with LUTS aged 50 or older were included from 2001 to 2005 and followed up until their death or the end of 2012. During the follow-up period, 1958 cases developed depression subsequently and were defined as the study group. 7832 patients without depression were then identified as control group, matching by age, gender, insurance premium, status of catastrophic illness certificate, and the index year in a 1:4 ratio. The primary outcome was the onset of dementia. LUTS, depression, dementia, and other comorbidities were defined by the International Classification of Disease, 9th Revision, Clinical Modification coding system. Cox hazards models and Aalen Johansen curves were applied to measure the influence of depression on the risk of dementia in patients with LUTS.

Results

The crude incidence of depression among people with LUTS was 12.3%. The incidence of dementia in the depression group was significantly higher than that in the control group (12.2% versus 8.9%; P < 0.001). Depression was associated with a significantly greater risk of subsequent dementia after adjusted for socioeconomic status, number of outpatient visits and multiple comorbidities (adjusted hazard ratio: 1.32; 95% confidence interval: 1.13–1.54).

Conclusions

Depression is a major risk factor for the onset of subsequent dementia in patients with LUTS. Early screening and interventions for depression in patients with LUTS may be important to maintain cognitive function.

Aberrant Default Mode Network Underlying the Cognitive Deficits in the Patients With Late-Onset Depression

Late-onset depression (LOD) is regarded as a risk factor or a prodrome of Alzheimer’s disease (AD). Moreover, LOD patients with cognitive deficits have the higher risk of subsequent AD. Thus, it is necessary to understand the neural underpinnings of cognitive deficits and its pathological implications in LOD. Consistent findings show that the default mode network (DMN) is an important and potentially useful brain network for the cognitive deficits in LOD patients. In recent years, genetics has been actively researched as a possible risk factor in the pathogenesis of LOD. So, in this review, we discuss the current research progress on the cognitive deficits and DMN in LOD through a combined view of brain network and genetics. We find that different structural and functional impairments of the DMN might be involved in the etiological mechanisms of different cognitive impairments in LOD patients.

When Cognitive Decline and Depression Coexist in the Elderly: CSF Biomarkers Analysis Can Differentiate Alzheimer's Disease from Late-Life Depression

Late-life depression (LLD) and Alzheimer's Disease (AD) are the two most frequent neuropsychiatric disorders affecting elderly. LLD and AD may clinically present with depressive and cognitive symptoms. Therefore, when cognitive decline is coupled with depression in the elderly, the differential diagnosis between LLD and AD could be challenging. The aim of the present study was to evaluate in a population of elderly patients affected by depression and dementia the usefulness of CSF AD biomarkers (tau proteins and β-amyloid₄₂–Aβ₄₂) and 2-[18F]fluoro-2-deoxy-d-glucose positron emission tomography (18FFDG-PET) in early differentiating LLD from AD. Two hundred and fifty-six depressed and demented patients, after performing CSF AD biomarkers and 18FFDG-PET, were distributed in two groups on the basis of the current diagnostic guidelines for AD (n = 201) and LLD (n = 55). Patients were then observed for 2 years to verify the early diagnosis. After the 2 year follow-up we compared AD and LLD patients' CSF and 18FFDG-PET data obtained at baseline to a group of age- and sex-matched controls. We found CSF Aβ₄₂ levels significantly higher in LLD compared to AD patients. Remarkably, CSF Aβ₄₂ levels of LLD patients (range between 550 and 1204 pg/mL) did not overlap with those of AD patients (range between 82 and 528 pg/mL). Moreover, we documented no differences in CSF AD biomarkers (Aβ₄₂ and tau proteins) when comparing LLD patients to controls. In addition, AD patients showed the significant reduction of 18FFDG-PET uptake in temporo-parietal regions compared to both controls and LLD. Conversely, LLD and control groups did not differ at 18FFDG-PET analysis, although LLD patients showed heterogeneous patterns of glucose hypometabolism involving cortical and subcortical brain areas. It is noteworthy that at the end of the clinical follow-up, patients owing to AD group showed the expected significant decline of cognitive performances, whereas patients assigned to LLD group improved cognition as depressive symptoms recovered. Hence, in case of co-existence of cognitive impairment and depression in the elderly, we propose CSF AD biomarkers analysis to early differentiate LLD from AD and properly target the patient's therapeutic strategy and clinical follow-up.

Utility of the Neurobehavioral Cognitive Status Examination (COGNISTAT) in differentiating between depressive states in late-life depression and late-onset Alzheimer's disease: a preliminary study

BACKGROUND

It is often difficult to differentiate between the depressive states seen in late-life depression and late-onset Alzheimer' disease (AD) in the clinical setting.

METHODS

Thirty-four outpatients were recruited, all fulfilling the criteria of aged 65 years or above, scores of 14 or more on the Hamilton depression rating scale (HAM-D), and 26 or less on the Mini-Mental State Examination (MMSE). At the initial visit, they were administered the Neurobehavioral Cognitive Status Examination (COGNISTAT). At 1 month, a diagnosis of either senile depression (n = 24) or Alzheimer' disease (n = 10) was made.

RESULTS

The COGNISTAT revealed that the late-life depression group showed significantly higher scores in orientation and comprehension subtests compared with the AD group. At the study endpoint (6 months after treatment), MMSE detected significant improvements in the late-life depression group (n = 15), but no changes in the late-onset AD group (n = 7). Scores for memory, similarities, and judgment on the second COGNISTAT were significantly improved in the depressed group, whereas calculation scores deteriorated significantly in the AD group.

CONCLUSION

The COGNISTAT could prove useful in differentiating late-life depression from late-onset AD, despite similar scores on MMSE.

Serum folate and B12 levels in association with cognitive impairment among seniors: results from the VELESTINO study in Greece and meta-analysis

OBJECTIVE

To summarize existing evidence on the effect of serum folate and vitamin B12 levels on cognitive impairment among elders via a meta-analysis, also including unpublished data from a cross-sectional study of seniors ( > 65 years) residing in Velestino, Greece.

METHOD

Serum measurements and Mini-Mental State Examination (MMSE) assessments were available for 593 Velestinians. In addition, 12 studies availing data on folate blood levels (N = 9,747) and 9 on B12 (N = 8,122) were identified following a search algorithm; pooled effect estimates were derived.

RESULTS

Cognitive impairment (MMSE < 24) among Velestenians was associated with lower education level in both genders; decreased social activity, depressive symptoms and low folate levels in males; older age in females. Meta-analyses showed an adverse effect of low-folate levels on cognition (OR: 1.66, 95% CI: 1.40-1.96); B12 was nonsignificantly associated (OR: 1.11, 95% CI: 0.88-1.40).

DISCUSSION

Low folate levels are associated with cognitive impairment of seniors; underlying pathophysiological mechanisms should be further explored.

Non-cognitive symptoms and related conditions in the Alzheimer's disease: a literature review

The Alzheimer's disease is considered a progressive cognitive disorder; however, several non-cognitive symptoms accompany all stages of the disease, appearing at times before the cognitive symptoms become manifest. This article reviews the literature on non-cognitive symptoms normally related to the Alzheimer's disease, including gait and balance dysfunction, olfactory dysfunction, diabetes, pain, and psychiatric symptoms.

Effectiveness of Electroconvulsive Therapy for Depression and Cotard's Syndrome in a Patient with Frontotemporal Lobe Dementia

In the field of psychogeriatrics, the differential diagnosis of depression and dementia, as well as the treatment of depression and comorbid dementia, is an important issue. In this paper, the authors present the case of a 72-year-old woman with Cotard's syndrome and frontotemporal dementia (FTD) who was admitted to a psychiatric hospital with delusions of negation accompanied by depressive symptoms. Pharmacotherapy over a 2-year hospitalization was unsuccessful, and she was subsequently transferred to our university hospital. A total of 18 sessions of electroconvulsive therapy released her from psychomotor inhibition, appetite loss, and Cotard's delusions. The indication for electroconvulsive therapy in patients with dementia is discussed.