Depression, cognition, and functional ability in patients with Alzheimer's disease

The Associations Between Neuropsychiatric Symptoms and Cognition in People with Dementia: A Systematic Review and Meta-Analysis

Most people with dementia experience neuropsychiatric symptoms (NPS), including anxiety, depression or disinhibition. There is growing interest in the relationship between NPS and cognitive impairment, but data is still limited. This study aimed to investigate the specific associations between NPS and cognition in people with dementia. MEDLINE, EMBASE and PsycINFO were searched for published, peer-reviewed studies of associations between at least one NPS and one cognitive ability in people with dementia. The quality of the studies was assessed with the NIH National Heart, Lung and Blood Institute's quality assessment tools. A meta-analysis was conducted using Robumeta package for R. Ninety studies were included. We found significant associations between NPS, global cognition and cognitive domains, e.g. apathy was associated with global cognitive and memory impairment; dysphoria was associated with worse attention; delusions with executive dysfunction. Increased NPS in people with dementia are associated with worse cognitive performance. There were few studies looking at associations between some neuropsychiatric clusters and cognitive abilities, and there was little research on causal relationships. Our review was limited by the inclusion of studies that reported associations in specific formats, and most included people with a diagnosis of Alzheimer's disease (AD). However, given the large number of studies, this is unlikely to have biased results. More research is needed that includes diverse people with different dementia syndromes. Registration: PROSPERO 2020 CRD42020165565.

Capturing Cognitive Aging in Vivo: Application of a Neuropsychological Framework for Emerging Digital Tools

As the global burden of dementia continues to plague our healthcare systems, efficient, objective, and sensitive tools to detect neurodegenerative disease and capture meaningful changes in everyday cognition are increasingly needed. Emerging digital tools present a promising option to address many drawbacks of current approaches, with contexts of use that include early detection, risk stratification, prognosis, and outcome measurement. However, conceptual models to guide hypotheses and interpretation of results from digital tools are lacking and are needed to sort and organize the large amount of continuous data from a variety of sensors. In this viewpoint, we propose a neuropsychological framework for use alongside a key emerging approach-digital phenotyping. The Variability in Everyday Behavior (VIBE) model is rooted in established trends from the neuropsychology, neurology, rehabilitation psychology, cognitive neuroscience, and computer science literature and links patterns of intraindividual variability, cognitive abilities, and everyday functioning across clinical stages from healthy to dementia. Based on the VIBE model, we present testable hypotheses to guide the design and interpretation of digital phenotyping studies that capture everyday cognition in vivo. We conclude with methodological considerations and future directions regarding the application of the digital phenotyping approach to improve the efficiency, accessibility, accuracy, and ecological validity of cognitive assessment in older adults.

Rural-Urban Inequalities in Poor Self-Rated Health, Self-Reported Functional Disabilities, and Depression among Chinese Older Adults: Evidence from the China Health and Retirement Longitudinal Study 2011 and 2015

The household registration system (Hukou) in China classifies persons into rural or urban citizens and determines eligibility for state-provided services and welfare. Not taking actual residence into account may underestimate rural–urban differences. This study investigates rural–urban inequalities in self-reported health outcomes among older adults aged 60+, taking into account both Hukou and actual residence, adjusting for sociodemographic determinants, based on the China Health and Retirement Longitudinal Study (CHARLS) in 2011 and 2015. Self-Rated Health (SRH) was assessed with a single question, functional abilities were assessed with the Basic Activities of Daily Living (BADLs) and Instrumental Activities of Daily Living (IADLs) scales, and depression was assessed with the 10-item version of the Center for Epidemiologic Studies Depression Scale. Rural respondents had poorer socioeconomic status and higher prevalence of poor SRH, functional disabilities, and depression than urban respondents in both years, which were closely related to rural–urban differences in educational level and income. Impairments appeared at a younger age among rural respondents. Analyses using only Hukou registration and not actual residence resulted in underestimation of rural–urban differences. This study may serve as a basis for interventions to address rural–urban differences in health and social services and reduce health inequalities among Chinese older adults.

Network structures and temporal stability of self- and informant-rated affective symptoms in Alzheimer's disease

BACKGROUND

Affective symptoms in Alzheimer's disease (AD) can be rated with both informant- and self-ratings. Information from these two modalities may not converge. We estimated network structures of affective symptoms in AD with both rating modalities and assessed the longitudinal stability of the networks.

METHODS

Network analyses combining self-rated and informant-rated affective symptoms were conducted in 3198 individuals with AD at two time points (mean follow-up 387 days), drawn from the NACC database. Self-rated symptoms were assessed by Geriatric Depression Scale, and informant-rated symptoms included depression, apathy and anxiety questions from Neuropsychiatric Inventory Questionnaire.

RESULTS

Informant-rated symptoms were mainly connected to symptoms expressing lack of positive affect, but not to the more central symptoms of self-rated worthlessness and helplessness. Networks did not differ in structure (p = .71), or connectivity (p = .92) between visits. Symptoms formed four clinically meaningful clusters of depressive symptoms and decline, lack of positive affect, informant-rated apathy and anxiety and informant-rated depression.

LIMITATIONS

The symptom dynamics in our study could have been present before AD diagnosis. The lack of positive affect cluster may represent a methodological artefact rather than a theoretically meaningful subgroup. Requiring follow-up lead to a selection of patients with less cognitive decline.

CONCLUSIONS

Informant rating may only capture the more visible affective symptoms, such as not being in good spirits, instead of more central and severe symptoms, such as hopelessness and worthlessness. Future research should continue to be mindful of differences between self- and informant-rated symptoms even in earlier stages of AD.

Comparing patient and informant ratings of depressive symptoms in various stages of Alzheimer's disease

OBJECTIVE

Using a multimethod approach, this study assessed the relationship between patient and informant ratings of depression in Alzheimer's disease (AD) in a manner that better represents the progressive course of AD, and allows for elucidation of specific cognitive domains that may explain changes in respondent agreement.

METHOD

Case data (N = 16,297) were provided by the National Alzheimer's Coordinating Center (NACC). A series of contingency analyses were performed to assess the relationship between patient and informant agreement across levels of impairment in individuals with AD. Patients and informants were placed into groups (i.e., not impaired, mild impairment, moderate impairment, severe impairment) based on patients' performance on multiple indicators of global cognitive functioning, as well as measures of attention, working memory, processing speed, executive functioning, language, and episodic learning and memory.

RESULTS

Across measures, greater impairment was significantly (p < .001) associated with decreases in patient-informant congruence and increases in rates of patients denying depression when informants endorsed observing features of the same. These inconsistencies were most pronounced in the mildest stages of impairment. For a subset of the sample, rates of patients reporting depressive symptoms when informants denied observing the same also increased alongside worsening impairment. Incremental impairment in episodic learning (χ² = 805.25) and memory (χ² = 856.94) performance were most closely associated with decreases in respondent agreement. Patient-informant relationship type did not appear to mediate the response patterns observed.

CONCLUSIONS

Mild impairment in AD patients, particularly in episodic learning and memory functioning, is significantly associated with decreases in patient-informant agreement regarding the presence of depressive symptoms. These results suggest that even at the earliest stages of AD informant reports should be used to corroborate patients' reporting. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Neuropsychiatric symptoms and activities of daily living in Alzheimer's disease: ALSOVA 5-year follow-up study

BACKGROUND

Neuropsychiatric symptoms (NPSs) in Alzheimer's disease (AD) are related to activities of daily living (ADLs), but longitudinal studies are sparse.

OBJECTIVES

We investigated which NPSs were related to decline in instrumental ADLs (IADLs) and basic ADLs (BADLs) in a 5-year follow-up of individuals with AD.

METHODS

ALSOVA 5-year follow-up study data of 236 individuals with very mild or mild AD at baseline and their caregiver were analyzed. IADLs and BADLs were assessed with Alzheimer's Disease Cooperative Study ADL inventory, and NPSs with Neuropsychiatric Inventory at annual follow-up visits. Generalized estimating equations (GEEs) were used for longitudinal data analysis, and NPS-ADL networks were estimated to demonstrate symptom interactions.

RESULTS

Apathy [rate ratio (RR) 1.23, 95% CI 1.06-1.44, p = 0.007], aberrant motor behavior (RR 1.24, 95% CI 1.07-1.44, p = 0.005), and appetite disturbances (RR 1.22, 95% CI 1.06-1.41, p = 0.005) were related to impairment in BADLs, and the same symptoms (RR 1.13, 95% CI 1.07-1.21, p < 0.001; RR 1.13, 95% CI 1.07-1.20, p < 0.001; RR 1.14; 95% CI 1.08-1.21, p < 0.001, for apathy, aberrant motor behavior, and appetite disturbances, respectively), in addition to delusions (RR 1.09, 95% CI 1.03-1.15, p = 0.004), were related to IADL impairment. Symptom networks varied at different time points.

CONCLUSION

As AD progresses, common (apathy) and uncommon NPSs (aberrant motor behavior, appetite disturbances, delusions) seem to be related to ADLs through various symptom interactions. Previous literature suggests that frontal pathology could underlie these relationships.

The relationship between perceived functional difficulties and the ability to live well with mild-to-moderate dementia: Findings from the IDEAL programme

OBJECTIVES

The objectives of the study are to investigate how different levels of functional ability relate to quality of life, well-being, and satisfaction with life, conceptualised as reflecting capability to "live well" in people with dementia.

METHODS/DESIGN

Participants were 1496 people with mild-to-moderate dementia and 1188 informants who completed baseline assessments in the Improving the experience of Dementia and Enhancing Active Life (IDEAL) cohort study. Total self-rated and informant-rated scores on the Functional Activities Questionnaire were split into six ability levels to monitor how poorer functioning impacts the ability to live well. We also investigated the potential influence of sociodemographic and diagnostic variables, depression, cognition, and carer stress.

RESULTS

Multivariate multiple regression models found that people with dementia who had the greatest functional impairment according to self-ratings and informant ratings had poorer living well scores than those with the least functional impairment. Sociodemographic and diagnostic factors and cognition had little impact on effect sizes. For self-ratings, depression attenuated the relationship between functional ability and living well, whereas carer stress attenuated informant ratings.

CONCLUSIONS

People with dementia with the least functional impairments had greater capability to live well than those with the most functional impairment. Even subtle perceived difficulties in functional ability had a detrimental effect on the ability of people with dementia to live well. Depression in people with dementia and carer stress in informants influenced these associations, and therefore, these factors should be routinely included in future research studies and clinical assessments.

Life-space mobility in older persons with cognitive impairment after discharge from geriatric rehabilitation

OBJECTIVES

To describe life-space mobility and identify its determinants in older persons with cognitive impairment after discharge from geriatric rehabilitation.

METHODS

A cross-sectional study in older community-dwelling persons with mild to moderate cognitive impairment (Mini-Mental State Examination, MMSE: 17-26) following geriatric rehabilitation was conducted. Life-space mobility (LSM) was evaluated by the Life-Space Assessment in Persons with Cognitive Impairment (LSA-CI). Bivariate analyses and multivariate regression analyses were used to investigate associations between LSM and physical, cognitive, psychosocial, environmental, financial and demographic characteristics, and physical activity behavior.

RESULTS

LSM in 118 older, multimorbid participants (age: 82.3 ± 6.0 years) with cognitive impairment (MMSE score: 23.3 ± 2.4 points) was substantially limited, depending on availability of personal support and equipment. More than 30% of participants were confined to the neighborhood and half of all patients could not leave the bedroom without equipment or assistance. Motor performance, social activities, physical activity, and gender were identified as independent determinants of LSM and explained 42.4% (adjusted R²) of the LSA-CI variance in the regression model.

CONCLUSION

The study documents the highly restricted LSM in older persons with CI following geriatric rehabilitation. The identified modifiable determinants of LSM show potential for future interventions to increase LSM in such a vulnerable population at high risk for restrictions in LSM by targeting motor performance, social activities, and physical activity. A gender-specific approach may help to address more advanced restrictions in women.

[Apathy, depression and cognitive functioning in patients with MCI and dementia]

BACKGROUND

In dementia, apathy and depression are often seen as one disorder because of the many overlapping symptoms. However, for therapy a correct differentiation is essential. Moreover, apathy and depression are likely both associated with different cognitive deficits and progression of the disease. In this research we give an overview of cognitive domains associated with apathy and depression in MCI patients and report how often both disorders occur in a population sample.

METHOD

We administered the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) to 117 cognitively healthy controls (GC), 97 patients with mild cognitive impairment (MCI) and 50 patients with dementia (DEM). In addition, the Apathy Evaluation Scale clinical version (AES-C) and the Geriatric Depression Scale (GDS) were administered.

RESULTS

The number of patients with apathy increased with cognitive decline with respectively 3.4%, 10.4% and 41.5% of patients in the GC, MCI and DEM group. The prevalence of isolated depression was highest in the MCI group (18.8%). Correlation analyses in the MCI group showed that apathy and not depression was associated with a deficit in encoding, attention and global cognitive functioning.

CONCLUSION

The prevalence of apathy and depressive symptoms is different in patients with MCI, DEM and GC, and within the MCI group apathy and depression are associated with different cognitive domains.

Evaluating PROMIS Physical Function Measures in Older Adults at Risk for Alzheimer's Disease

Activities of daily living can be affected by cognitive decline. Self-report measurement of functioning is attractive due to ease of data collection, low cost, and accessibility via technology-assisted means, and for understanding patient perspective. A concern is with reliability of such measurement as cognitive decline occurs. We compared a widely used, self-report “legacy” measure of functioning, Lawton and Brody’s Instrumental Activities of Daily Living Scale (IADLS), with a subset of physical functioning items from the Patient-Reported Outcomes Measurement Information System (PROMIS). The study sample consisted of 304 individuals of varying cognitive status: normal, mild cognitive impairment (MCI), or early dementia. An expert consensus method was used to select PROMIS functional items most relevant to neurocognitive disorder and to identify major functional sub-domains. Selected PROMIS functional subscales and the IADLS were then evaluated with respect to cognitive status. Few PROMIS functional items were useful in identifying MCI, while we reaffirmed the utility of the IADLS. Also, even mild depression levels were found to have negative effects on functioning according to both PROMIS and IADLS.

Early-versus Late-Onset Alzheimer Disease: Long-Term Functional Outcomes, Nursing Home Placement, and Risk Factors for Rate of Progression

BACKGROUND/AIMS

Whether age at onset influences functional deterioration in Alzheimer disease (AD) is unclear. We, therefore, investigated risk factors for progression in activities of daily living (ADL) and nursing home placement (NHP) in cholinesterase inhibitor (ChEI)-treated patients with early-onset AD (EOAD) versus late-onset AD (LOAD).

METHODS

This 3-year, prospective, observational, multicenter study included 1,017 participants with mild-to-moderate AD; 143 had EOAD (onset <65 years) and 874 LOAD (onset ≥65 years). Possible sociodemographic and clinical factors that could affect functional outcome and NHP were analyzed using mixed-effects models and logistic regression, respectively.

RESULTS

Younger individuals exhibited longer illness duration before AD diagnosis, whereas 6-month functional response to ChEI therapy, 3-year changes in ADL capacities, time from diagnosis to NHP, and survival time in nursing homes were similar between the groups. In LOAD, a higher ChEI dose, no antidepressant use, and lower education level were protective factors for slower instrumental ADL (IADL) decline. In EOAD, antihypertensives/cardiac therapy implied faster IADL progression but lower risk of NHP.

CONCLUSION

This study highlights the clinical importance of an earlier diagnosis and treatment initiation and the need for functional evaluations in EOAD. Despite the age differences between EOAD and LOAD, a similar need for nursing homes was observed.

Need-driven dementia-compromised behavior: An alternative view of disruptive behavior

The disruptive behavior of persons with dementia is a problem of considerable clinical interest and growing scientific concern. This paper offers a view of these behaviors as expressions of unmet needs or goals and provides a comprehensive conceptual framework to guide further research and clinical practice. Empiricalfindings and clinical impressions related to wandering, vocalizations and aggression to support and illustrate the framework are presented

The influences of psychotic symptoms on the activities of daily living of individuals with Alzheimer disease: a longitudinal analysis

OBJECTIVES

Psychotic symptoms associated with Alzheimer Disease (AD) contribute to excess functional dependence. Longitudinal studies have generally examined the association between rates of functional decline and the occurrence of psychotic symptoms from either a single evaluation or from multiple evaluations rather than through changes in frequency and severity of symptoms. Although the presence or absence of psychotic symptoms at initial or follow-up examinations may be associated with changes in functional status, the nature of the relationship between changes in these domains cannot be inferred. We examine the association between changes in the frequency of psychotic symptoms and changes in dependence in activities of daily living (ADL) over a period ranging from 1 to 74 months (median = 17.7).

METHOD

Data from a cohort of 234 individuals referred to a memory clinic were analyzed using multilevel linear regression. Information on ADL, behavioral and psychological symptoms, depression, and cognition was collected.

RESULTS

An increase in the frequency of psychotic symptoms had a unique influence on the deterioration of basic ADL, after controlling for demographic variables, changes in cognition, depression, and other behavioral and psychological symptoms (B = -.017, p = .003). However, changes in psychotic symptoms did not significantly contribute to declines in the ability to perform instrumental ADL (B = -.008, p = .439).

CONCLUSION

Changes in psychotic symptoms may influence basic but not instrumental ADL over time. These findings may have ramifications for studies and treatment plans for individuals with AD who demonstrate psychotic symptoms.

Accounting for functional loss in Alzheimer's disease and dementia with Lewy bodies: beyond cognition

BACKGROUND

The relative contributions of cognitive, motor, and behavioral deficits to the impairment of physical or instrumental activities of daily living (ADLs) may differ in patients with dementia with Lewy bodies (DLB) and Alzheimer's disease (AD).

METHODS

Multiple linear regression analyses were used to identify the amount of variability in physical self-maintenance and instrumental ADL ratings predicted by cognitive, motor, and behavioral indices separately for patients with autopsy-diagnosed DLB (n = 39) or AD (n = 39).

RESULTS

Motor dysfunction accounted for significant variance in physical ADLs in DLB (R(2) change = 0.17), whereas behavioral (R(2) change = 0.23) and motor dysfunction (R(2) change = 0.13) accounted for significant variance in AD. Motor (R(2) change = 0.32) and cognitive (R(2) change = 0.10) dysfunction accounted for significant variance in instrumental ADLs in DLB, whereas cognitive (R(2) change = 0.36) and behavioral (R(2) change = 0.12) dysfunction accounted for significant variance in AD.

CONCLUSIONS

Cognitive, motor, and behavioral deficits contribute differently to ADL changes in DLB and AD. Thus, treatments designed to ameliorate a certain aspect of AD or DLB (e.g., cognitive dysfunction) may have a larger impact on everyday functioning in one disorder than the other.

Baseline disability in activities of daily living predicts dementia risk even after controlling for baseline global cognitive ability and depressive symptoms

OBJECTIVES

Late-life disability in activities of daily living (ADL) is theorized to be driven by underlying cognitive and/or physical impairment, interacting with psychological and environmental factors. Although we expect that cognitive deficits would explain associations between ADL disability and dementia risk, the current study examined ADL as a predictor of future dementia after controlling for global cognitive status.

METHODS

The population-based Cache County Memory Study (N = 3547) assessed individuals in four triennial waves (average age 74.9 years, years of education 13.36 years; 57.9% were women). Cox proportional hazards regression models assessed whether baseline ADL disability (presence of 2+ Instrumental ADL and/or 1+ Personal ADL) predicted incident dementia after controlling for APOE status, gender, age, baseline cognitive ability (Modified Mini-mental State Exam, 3MS-R; adjusted for education level), and baseline depressive symptoms (Diagnostic Interview Schedule).

RESULTS

Over the course of study, 571 cases of incident dementia were identified through in-depth cognitive assessment, ending in expert consensus diagnosis. Results from Cox models suggest that ADL disability is a statistically significant predictor of incident dementia (adjusted hazard ratio = 1.83, p < 0.001), even after controlling for covariates.

CONCLUSIONS

Findings suggest that ADL disability offers unique contributions in risk for incident dementia, even after controlling for global cognitive status. We discuss how physical impairment and executive function may play important roles in this relationship, and how ADL is useful, not just a diagnostic tool at, or after dementia onset, but also as a risk factor for future dementia, even in individuals not impaired on global cognitive tests.

Predicting functional ability in mild cognitive impairment with the Dementia Rating Scale-2

BACKGROUND

We examined the utility of cognitive evaluation to predict instrumental activities of daily living (IADLs) and decisional ability in Mild Cognitive Impairment (MCI).

METHODS

Sixty-seven individuals with single-domain amnestic MCI were administered the Dementia Rating Scale-2 (DRS-2) as well as the Everyday Cognition assessment form to assess functional ability.

RESULTS

The DRS-2 Total Scores and Initiation/Perseveration and Memory subscales were found to be predictive of IADLs, with Total Scores accounting for 19% of the variance in IADL performance on average. In addition, the DRS-2 Initiation/Perseveration and Total Scores were predictive of ability to understand information, and the DRS-2 Conceptualization helped predict ability to communicate with others, both key variables in decision-making ability.

CONCLUSIONS

These findings suggest that performance on the DRS-2, and specific subscales related to executive function and memory, is significantly related to IADLs in individuals with MCI. These cognitive measures are also associated with decision-making-related abilities in MCI.

Functional correlates of instrumental activities of daily living in mild Alzheimer's disease

Instrumental activities of daily living (IADL) includes the integration of task-initiation, -planning, and -performance. Little is known on the cerebral perfusion correlates of these subcomponents of IADL in Alzheimer's disease (AD). In 121 AD patients, cerebral perfusion, using single-photon emission computed tomography, in 13 bilateral regions of interest (ROI) and the perfusion correlates of IADL subcomponents, rated on the Disability Assessment in Dementia scale, were explored. Significant correlations were observed between IADL initiation and multiple bilateral prefrontal-striatal-anterior cingulate ROI (p < 0.01), IADL planning and right occipital ROI (p < 0.05), and IADL performance and right parietal ROI (p < 0.05). Multiple regression, accounting for age, cognitive impairment, and depression severity, revealed significant relationship between right basal ganglia perfusion and IADL-initiation (R = 0.6, R(2) = 0.39, F(4,117) = 17.8, SE = 1.56; p < 0.001) and right occipital perfusion and IADL-planning (R = 0.6, R(2) = 0.34, F(4,117) = 19.5, SE = 1.47; p < 0.001). In AD, perfusion correlates of these subcomponents may be linked to the heterogenous cognitive processes involved in IADL.

Correlates of functional dependence among recently admitted assisted living residents with and without dementia

OBJECTIVES

To describe and contrast functional dependency (FD) levels among recently admitted AL residents with and without dementia and to assess the differential contribution of cognitive, behavioral, medical, and social factors on FD within each group.

DESIGN

A cross-sectional study.

SETTING

A random sample of 28 AL facilities in the Central Maryland region.

PARTICIPANTS

Two hundred and sixty-two AL residents assessed less than 1 year after admission.

MEASUREMENTS

Participants were given comprehensive in-person dementia assessments. Cognitive, behavioral, medical, and social factors were also assessed. FD was operationalized as impairment in activities of daily living.

RESULTS

The 59% of residents with dementia had higher levels of FD (P < .001) and were more likely to require assistance in all assessed task-specific ADL domains (P < .001) except mobility (P = .653). In multivariate models, global cognition, medical health status, and presence of diabetes explained 43% of the variance in FD in the dementia group. Twenty-five percent of the variance in FD was explained by depression, neuropsychiatric symptoms, and global cognition in those without dementia.

CONCLUSIONS

Recently admitted AL residents have substantial levels of FD. FD is higher among residents with dementia compared with those without and the association of cognitive, mental health, and medical variables with FD differ as a function of dementia status. Future research should examine how these dimensions affect FD longitudinally and whether they may serve as targets for interventions and quality of care improvement initiatives.

Awareness of deficits in financial abilities in patients with mild cognitive impairment: going beyond self-informant discrepancy

OBJECTIVE

Self and informant reports of functional abilities are weighted heavily in diagnostic decision making regarding mild cognitive impairment (MCI). However, it is unclear whether patients with MCI are fully aware and provide reliable estimates of their functional status. In this study, the authors used three different approaches to examine accuracy of self-report of financial abilities among patients with MCI.

DESIGN

Cross-sectional, case-comparison group study.

SETTING

University medical center.

PARTICIPANTS

Seventy-four patients with MCI and their informants, and 73 cognitively healthy older adults and their informants.

MEASUREMENTS

The authors compared MCI patients' report of their financial abilities with their performance on an objective measure of financial capacity. The authors also compared informant reports of patients' abilities with patients' objective test performance, and informant reports with patients' self-report.

RESULTS

The authors found that the discrepancy between self-report and objective performance was higher among MCI patients compared with the cognitively healthy older adults on the financial domains of Checkbook Management, Bank Statement Management, and Bill Payment, and on overall financial capacity. The authors also found that MCI patients with poorer global cognition overestimated their financial abilities whereas those with higher depressive symptoms underestimated their financial abilities. Overall, MCI patients were better at estimating their financial abilities than their informants.

CONCLUSIONS

Patients with MCI are not fully aware of deficits in their financial abilities. Both cognitive impairment and depression impact MCI patients' self-reported functioning. In addition, MCI informants misestimate patients' financial abilities. This raises concerns about the widespread use of informant report as the gold standard against which to evaluate patient self-report of functioning.

Impact of adult day services on behavioral and psychological symptoms of dementia

PURPOSE

This study explored whether adult day service (ADS) use was associated with reductions in behavioral and psychological symptoms of dementia (BPSD) in individuals with dementia.

DESIGN AND METHODS

We used a quasi-experimental design to compare a group of 133 persons with dementia (PWDs) who initially enrolled in an ADS program to a control group not using these services (n = 68). Caregivers used a 24-hour log on multiple, consecutive days to report on five domains of BPSD.

RESULTS

We used growth-mixture modeling techniques to model change in the BPSD domains over a 2-month period as well as to handle the preponderance of zeros that were inherent in the data. Results showed a relationship between ADS use and caregivers' report of fewer nighttime sleep-related problems for their PWDs. We found trends for other domains, specifically depressive symptoms and agitated behavior, but no significant group differences emerged for these and the other domains.

IMPLICATIONS

The findings of ADS use on PWDs' duration of nighttime sleep problems provide some evidence of the benefits of ADS; the findings also support its utility as part of the continuum of care for PWDs and their caregivers. For other behavior domains, enhanced or more targeted behavioral strategies coupled with ADS might offer caregivers and their PWDs the best possible combination for ameliorating BPSD.

Relation between corticotropin-releasing hormone neuron number in the hypothalamic paraventricular nucleus and depressive state in Alzheimer's disease

BACKGROUND/AIMS

Depression occurs in 20-50% of the Alzheimer disease (AD) patients. It is not known whether depression in AD shares its pathophysiology with depressive disorder. Previously we found a fourfold increase of corticotropin-releasing hormone (CRH)-immunoreactive (IR) neurons in the hypothalamic paraventricular nucleus in depression. The objective of the present study was to find out whether in depression in AD the same phenomenon of an increased number of CRH-IR neurons could be observed.

METHODS

Post-mortem brain tissue was obtained from a cohort of 23 AD patients prospectively studied using the Cornell Scale for Depression in Dementia to measure depressive symptoms. The number of CRH-IR neurons was determined using immunocytochemistry and the Image Pro Plus analysis program.

RESULTS

A significant positive correlation was found between the Cornell scores and the number of CRH-IR neurons (p = 0.039) in AD patients.

CONCLUSION

These results suggest that depressive disorder and depression in AD share, at least partly, their pathophysiology.

Assessment of anxiety in dementia: an investigation into the association of different methods of measurement

The objectives were to compare patient and caregiver ratings of anxiety for individuals with Alzheimer's disease and investigate their association with ratings of patient depression. Participants were 95 community-dwelling Alzheimer's disease patients and their caregivers. Measurements included caregiver proxy ratings: Rating Anxiety in Dementia, the NeuroPsychiatric Inventory, the Revised Memory and Behavior Problems Checklist, and the Cornell Scale for Depression in Dementia. Patient self-assessments included the Clinical Anxiety Scale (adapted) and the Geriatric Depression Scale. Correlations among anxiety measures ranged from rho = .16 to .40, whereas correlations between anxiety and depression scales ranged from rho = .03 to .66. Overlap among items across both anxiety and depression scales appeared to be the most important factor in determining these associations. Current scales for anxiety in dementia differ in their construction of symptoms and can overlap considerably with depression scales. Because of this, measures inadequately distinguish anxiety from depression in individuals with Alzheimer's disease. The measurement of anxiety in dementia needs additional refinement.

A home health care approach to exercise for persons with Alzheimer's disease

Regular exercise is a mainstay of preventive health care for individuals of all ages. Research with older adults has shown that exercise reduces risk of chronic illness, maintains mobility and function, enhances mood, and may even improve cognitive function. For individuals with dementia, exercise programs are particularly likely to improve health, mood, and quality of life; the challenge at this time is to make exercise accessible and enjoyable, demonstrate its benefits, and convince family caregivers of its worth for individuals with dementia. Home health providers are uniquely positioned to assist caregivers in developing and implementing a home exercise program for their care recipient with dementia. Results of a controlled critical trial conducted at the University of Washington have demonstrated the feasibility and efficacy of a home health exercise and problem solving intervention (Reducing Disability in Alzheimer's Disease, or RDAD) for decreasing physical, psychological, and behavioral disabilities associated with dementia. This article describes the RDAD program, discusses the role of home health providers in its delivery, and provides an example of its implementation.

Depressive symptoms in Alzheimer's disease: natural course and temporal relation to function and cognitive status

OBJECTIVES

To examine the natural course of depressive symptoms in patients with probable Alzheimer's disease (AD), specifically, the temporal relationship between depressive symptoms, function, and cognitive status.

DESIGN

Multicenter cohort study with follow-up of up to 14 years.

SETTING

Patients from the two Multicenter Study of Predictors of Disease Course in Alzheimer's Disease (Predictors Study) cohorts were recruited at five sites in the United States and Europe.

PARTICIPANTS

Patients diagnosed with probable AD (n=536) enrolled in a longitudinal study (Predictors Study).

MEASUREMENTS

Depressive symptoms were evaluated at 6-month intervals using the Columbia Scale for Psychopathology in Alzheimer's Disease. The Modified Mini-Mental State (3MS) and Blessed Dementia Rating Scale (BDRS) were used to assess cognitive status and functional activity, respectively.

RESULTS

The prevalence of depressive symptoms was stable over the first 3 years of follow-up, at approximately 40%. There was a significant drop to 28% and 24% in the fourth and fifth years of follow-up, respectively. Time-dependent Cox analysis revealed that functional activity (BDRS) but not cognitive status (3MS) was a significant predictor of the first episode of depressive symptoms during follow-up. Generalized estimating equation analyses showed that AD duration and functional activity but not cognitive status were significantly related to depressive symptoms over the entire follow-up period.

CONCLUSION

Depressive symptoms are common in AD, but their prevalence decreases over time. Examination of the temporal relationship between depressive symptoms and risk factors suggests that decline in function but not in cognition precedes the first episode of depressive symptoms in patients with probable AD.

Factors that relate to activity engagement in nursing home residents

Many nursing home residents are unoccupied and at risk for poor health outcomes because of inactivity. The purpose of this study was to identify characteristics of residents with dementia that predict engagement in activities when activities are implemented under ideal conditions. Data from a clinical trial that tested the efficacy of individually prescribed activities were used to address the study aim. Thirty subjects were videotaped daily for 12 days during 20-minute activity sessions. Measures of engagement (time on task and level of participation) were taken from these videotapes. Univariate logistic regression analyses indicated that cognitive status and physical function explained a significant amount of variance in engagement. Efforts to promote function may facilitate even greater benefits from prescribed activities by improving capacity for engagement.

Factors affecting outpatient rehabilitation outcomes in elders

PURPOSE

To identify factors affecting outpatient rehabilitation outcomes in elders.

DESIGN

A retrospective cohort design was used to explore factors affecting outpatient rehabilitation outcomes in elders.

METHODS

Analyses of health records from a nurse-managed comprehensive outpatient rehabilitation facility were conducted. Data pertinent to the study were abstracted from 201 health records, including scores from three standard instruments: the Functional Independence Measure, the Mini-Mental State Examination, and the Geriatric Depression Scale, to construct study variables. Multivariate and stepwise regression analyses were performed.

FINDINGS

Cognitive impairment was associated with lower admission and discharge function, but not with rehabilitation outcomes (functional gain, rehabilitation efficiency, days of service, and discharge location). Age > or = 80 years, admission function, and the interaction of age > or = 80 years and admission function affected functional gain and rehabilitation efficiency. Older age, being Black, and having more medical comorbidities were associated with days of service. None of these factors contributed to discharge location.

CONCLUSIONS

Cognitive impairment was not associated with outpatient rehabilitation outcomes. Rather, age > or = 80 years and function when admitted affected functional gain and rehabilitation efficiency in elders who participated in outpatient rehabilitation services.

Functional Outcomes for Older Adults with Cognitive Impairment in a Comprehensive Outpatient Rehabilitation Facility

The purpose of the study was to examine functional outcomes of a nurse-managed, community-based Comprehensive Outpatient Rehabilitation Facility (CORF) for frail older adults and to compare the outcomes between two groups: older adults with cognitive impairment and those with intact cognition. A retrospective cohort design using healthcare record abstraction was used for the study. Two hundred and one older adults who were admitted to the CORF from the end of 1997 to early 1999 were included in the study. Data were abstracted from healthcare records, including clinician-generated Mini-Mental State Examination, Geriatric Depression Scale, and Functional Independence Measure scores from the healthcare records and investigator-constructed measures of functional gain, rehabilitation efficiency, days of service, and discharge location. Multivariate regression analyses were performed to compare rehabilitation outcomes between the two groups. Regardless of cognitive status, all subjects improved significantly in their levels of functional dependence through participating in this outpatient rehabilitation program (P<.001). Subjects with cognitive impairment exhibited more functional dependence at baseline and discharge than did their cognitively intact counterparts. Nevertheless, there was no difference between the two groups in functional gain (P=.63), rehabilitation efficiency (P=.66), days of service (P=.83), or discharge location (P=.69). Therefore, despite their greater degree of functional dependence on admission, older adults with cognitive impairment benefited from this CORF without requiring more days of service and should thus be referred for rehabilitation services.

Mayo's Older African American Normative Studies: norms for the Mattis Dementia Rating Scale

Normative data are presented for older African Americans on the Mattis Dementia Rating Scale (DRS). These data were collected as part of Mayo's Older African Americans Normative Studies (MOAANS) in an effort to develop age-appropriate norms for African Americans elders on commonly used measures in neuropsychological assessment. In this study, the DRS was administered to 307 MOAANS participants ranging in age from 56 to 94 years. Age-corrected subtest and total scores were derived based on percentile ranks from actual frequency distributions across seven age ranges. Also presented is a regression-based computational formula that may be applied to the age-corrected DRS total score to further correct for years of education. These norms should help improve interpretation of DRS performance in African Americans and allow for greater diagnostic accuracy in patients with early cognitive decline.

Major depression as a risk factor for early institutionalization of dementia patients living in the community

OBJECTIVE

Although depression is known to be frequently associated with dementia, it is nonetheless under-diagnosed and under-treated among this patient population. Its effect on outcome for dementia patients is thought to be substantial, because depression appears to induce higher than normal rates of disability as well as supplementary cognitive decline. The aim of this study was to measure the impact of major depression on the institutionalization rate of community-dwelling dementia patients.

DESIGN

Prospective cohort study.

SETTING

Paris, France.

PARTICIPANTS

Three-hundred forty-eight consecutive dementia outpatients of a geriatric clinic (mean age: 81 years, 69.8% women, 65.5% dementia of Alzheimer's type, mean baseline MMSE score: 20.5), followed between 1997 and 2002 (mean follow-up: 20.5 months).

RESULTS

Twenty-five percent of the patients met the criteria of major depression at baseline, and only 30.3% of these received antidepressant medication. Major depression at baseline was independently associated with nursing home admission within one year of the baseline assessment. Antidepressant medication tended to protect against this outcome, but not to a statistically significant extent.

CONCLUSIONS

Major depression at baseline is an independent risk factor for early institutionalization of dementia sufferers. Early institutionalization is defined in this study as nursing home placement within a year of diagnosis with dementia at our specialized outpatient center. The study highlights the need for better management of depression among dementia outpatients. Further investigation is needed to evaluate the protective effect of antidepressant medication (and/or non-pharmacological therapies) on the institutionalization rate.

Regional cerebral metabolism in early Alzheimer's disease with clinically significant apathy or depression

BACKGROUND

Alzheimer's disease (AD) is clinically characterized by cognitive impairment and behavioral disturbances. The aim of the study was to identify regional alterations in brain function associated with neuropsychiatric symptoms in early AD.

METHODS

Patients underwent measures of cerebral glucose metabolism applying positron emission tomography (PET) and (18)F-fluorodeoxyglucose. Neuropsychiatric symptoms were assessed using the Neuropsychiatric Inventory (NPI). Positron emission tomography images of patients suffering a neuropsychiatric symptom of clinical significance (NPI subscore for a specific item >/=4 points) were compared with the images of patients without the specific symptom under study (NPI subscore for a specific item = 0 points).

RESULTS

A total of 53 patients with AD (Mini-Mental State Examination [MMSE] 22.5 +/- 2.94 points) entered the study. Of all symptoms, apathy and depression were most frequently encountered. The patient group with apathy (n = 17) revealed significant decreases in left orbitofrontal regions when compared with patients free of apathy. Depression of clinical significance (n = 10) was associated with hypometabolism in dorsolateral prefrontal regions.

CONCLUSIONS

These findings support the notion that different functional circuits underlie apathy and depression in early AD.

The relationship between non-cognitive symptoms and functional impairment in Alzheimer's disease

OBJECTIVE

Cognitive impairment is an important determinant for functional impairment in Alzheimer's disease. The role of non-cognitive symptom is uncertain. The objective of this study was to investigate the role of non-cognitive symptoms as predictive factors for functional outcome in A.D.

METHODS

This was a retrospective study. Subjects were recruited from the Memory Clinic in Queen Mary Hospital over a two years period. Patients with diagnosis of probable A.D. by NINCDS-ADRDA were identified. Demographic data, Folstein Mini-Mental Status Examination (MMSE), Clinical Dementia Rating (CDR), Neuropsychiatric inventory (NPI), Barthel activities of daily living (ADL) as well as Lawton's Instrumental activities of daily living (IADL) were retrieved.

RESULTS

100 patients were identified. Univariate analysis identified statistically significant correlation between hallucination and disinhibition score with Barthel Index (r=-0.43, p <0.001; r=-0.30, p=0.002 respectively); hallucination and aberrant motor act score with Lawton's IADL (r=-0.21, p=0.038; r=-0.21, p=0.038). MMSE was statistical significantly correlated with the above two functional scores. NPI was not statistical significantly correlated with any one of the functional measures. Multivariate regression analyses showed that hallucination score was an independent predictive factors for the Barthel index but not for the Lawton's IADL. MMSE score was identified to be independent predictive factor for all functional measures.

CONCLUSIONS

Global cognitive impairment and hallucination was an important independent predictive factor for functional outcomes. Screening hallucination during the course of A.D. would be helpful. Further studies are needed to show the benefit of treatment of hallucination on the improvement of functional outcomes.

[Clinical features of ambulatory patients over 80 years of age followed for Alzheimer's disease. French prospective multicenter study REAL.FR]

PURPOSE

Twice out off three, patients with Alzheimer's disease (AD) are aged 80 and older. Very old patients are more frail, have social precariousness and have often polypathology. Few data are available about these elderly patients. The aim of our study was to analyse characteristics of AD patients aged 80 and older.

MATERIAL AND METHODS

This is a prospective, multicentric French study (REAL.FR) of a cohort of ambulatory AD patients, with Mini-Mental State values between 10 and 26. Clinical and social data at inclusion of patients aged 80 and older and patients younger were compared.

RESULTS

Six hundred eighty nine patients (488 women, 201 men) were included between April 2000 and June 2002. The mean age was 77.8 +/- 6.9 years. Two hundred sixty four patients (38%) were aged 80 and older. Those patients were more dependant for Activities of Daily Living (ADL) than younger patients (ADL score of Katz: 5.2 +/- 1.07 et 5.6 +/- 0.74 respectively; p < 0.001 and IADL (Instrumental Activities of Daily Living) score of Lawton: 7.3 +/- 3.57 et 9.3 +/- 1.57 respectively; p < 0.001). Duration of evolution of the disease were comparable between older and younger patients.

CONCLUSION

In our cohort, AD patients aged 80 and older had a weakest autonomy for the ADL than younger patients with the same stage of the disease. Results has implications on care. Following the cohort will permit to specify evolution of data.

Assessing and predicting functional impairment in Alzheimer's disease: the emerging role of frontal system dysfunction

Alzheimer's disease (AD) is associated with neuropsychologic and neuropsychiatric dysfunction and is a leading cause of disability among the elderly. Impairments in activities of daily living (ADL) contribute significantly to the disability reported among patients with AD and diminish quality of life for patients and their families. ADL assessment represents an important component of the diagnosis, tracking, and management of AD. Further, an understanding of the determinants of ADL dysfunction is critical for the early identification of individuals at risk for functional disability and for improved patient care. This manuscript reviews methods for assessing ADL in patients with AD and summarizes the available literature on the neuropsychologic and neuropsychiatric correlates of functional impairment in AD. The emerging role of frontal system dysfunction as an important determinant of ADL impairment is discussed, and recommendations for clinical practice and future research are provided.

Comorbidity of psychopathological domains in community-dwelling persons with Alzheimer's disease

In this post hoc analysis of baseline responses to the CERAD Behavior Rating Scale for Dementia in a clinical trial of interventions for agitation in Alzheimer's disease (AD), the authors investigated the distribution of, and relationships between, agitation, depression, and psychosis in 148 individuals with AD. Prevalence of depressive symptoms was highest (78.4%), followed by agitation (77.6%) and psychotic symptoms (69.3%); 51.1% of the sample had symptoms in all 3 domains. Cross-sectionally, psychotic symptoms were most closely associated with Mini-Mental State Examination (MMSE) scores, while agitation was less so. Depressive symptoms were relatively consistently prevalent across MMSE levels. After controlling for the presence of agitated symptoms, psychosis and depression were significantly associated, but neither symptoms of psychosis nor of depression were associated with agitation when depression or psychosis, respectively, was controlled for. Significant psychopathological comorbidity should be considered in the design of clinical trials targeting particular psychopathology in this disease population.

The dementias

Dementia affects about 5% of the elderly population over age 65 years and has an unexplained predominance in women and a low rate in some cultures. Different forms of dementia are now distinguished-Alzheimer's disease, dementia with Lewy bodies, frontotemporal dementia, and dementia secondary to disease, such as AIDS dementia. However, such nosological boundaries are being re-evaluated because different dementias are believed to have common underlying neuropathology. Neurochemical and neurobiological research has led to advances in understanding causes of dementia, and functional imaging has allowed identification of possible biomarkers; from these, a range of potential treatment approaches have arisen that focus on enhancement of neurotransmitter function, intervention at the level of amyloid production and deposition, and reduction of secondary risk factors such as hypertension, depression, and hypolipidaemia. Molecular diagnostic testing and genetic counselling for families with autosomal dominant early-onset dementia are new developments; however, this approach is not useful for late-onset dementia, in which the identified candidate susceptibility genes have a relatively small effect on risk. While fundamental research works towards new biological treatment strategies, much remains to be done in the area of disease management and the development of appropriate models of long-term care.

The Interaction of Cognitive and Emotional Status on Subsequent Physical Functioning in Older Mexican Americans: Findings From the Hispanic Established Population for the Epidemiologic Study of the Elderly

BACKGROUND

Optimal mental health (cognitive and emotional functioning) is an important factor for maintaining physical function. This study investigated the effects of cognitive and emotional status on subsequent lower body function in a population-based sample of older Mexican Americans.

METHODS

A 2-year prospective cohort study included Mexican Americans aged 65 and older who scored 18 or higher on the Mini-Mental State Examination (MMSE) at baseline interview and for whom complete data on a summary performance measure of lower body function were available at the 2-year follow-up interview (n = 2068). In-home interviews in 1993-1994 and 1995-1996 assessed sociodemographic variables, physical health conditions, cognitive function, emotional health, and lower body function.

RESULTS

In a multivariate analysis, continuous MMSE (b = 0.06; SE 0.02, p =.004) and Center for Epidemiological Studies-Depression (CES-D) (b = -0.53; SE 0.17, p =.002) scores at baseline were significantly associated with a summary performance measure of lower body function 2 years later, controlling for age, gender, marital status, education, selected medical conditions, and baseline summary performance score. A significant MMSE-by-CES-D interaction (p =.002) on summary performance score was also found after adjustments were made for age, gender, marital status, education, chronic health conditions, and baseline summary performance score. After adjusting for age, gender, marital status, education, selected medical conditions, and baseline summary performance score, subjects with low cognition (MMSE score 18-21) and high depressive symptoms (CES-D score > or = 16) were the most likely to have poor summary performance scores 2 years later (b = -0.95, SE 0.36, p =.008), followed by subjects with high cognition (MMSE score > 21) and high depressive symptoms (CES-D score > or = 16) (b = -0.57, SE 0.19, p =.003), and those with low cognition (MMSE score 18-21) and low depressive symptoms (CES-D score < 16) (b = -0.47, SE 0.22, p =.03), with high cognition (MMSE score > 21) and low depressive symptoms (CES-D score < 16) used as the reference.

CONCLUSIONS

Our results confirm prior investigations showing both cognitive function and emotional health predict subsequent lower body function, and extend these findings to older Mexican Americans. In addition, our results indicate that good emotional health moderates the impact of low cognition on subsequent physical function.

Longitudinal analysis of abnormal domains comprising mild cognitive impairment (MCI) during aging

Research directed towards early diagnosis and therapy of dementia demands rapid identification of prodromal mild cognitive impairment (MCI). A longitudinal study was designed to clarify whether different domains of cognitive impairment, tested by Mini-Mental State Examination (MMSE), help predict dementia. After 3.74+/-2.94 years of follow-up among 291 cognitively normative volunteers, 73 developed MCI. During the next 3.88+/-3.01 years of MCI follow-up, 47.9% of MCI developed dementia of Alzheimer's type (DAT), 20.5% of MCI developed vascular dementia (VaD) and 31.5% maintained persistent MCI at the time of data analysis. Total MMSE and subtest scores analyzed at MCI onset showed significant differences for serial seven subtest scores between DAT and persistent MCI (P<0.05). Rates of change in subtests of orientation and memory and total MMSE scores predicted DAT (P<0.01). Decreasing orientation and total MMSE scores predicted VaD conversion rates of MCI to DAT at 2 years were 20.06% among single-domain MCI versus 41.7% for multi-domain MCI (P<0.05). Subjects with MCI often have impaired cognitive domains other than memory and show rapid deterioration, which predicts DAT. VaD sometimes mimics DAT with subtle cognitive impairment appearing before onset of dementia.

Is mild cognitive impairment prodromal for vascular dementia like Alzheimer's disease?

BACKGROUND AND PURPOSE

Individuals with mild cognitive impairment (MCI) are at increased risk of Alzheimer's disease (AD) and probably other forms of dementia. Some subtypes of vascular dementia (VaD) may possess minor neuropathological changes of AD that may contribute to cognitive impairments. It was posited that MCI, identified by criteria described here, might present as a prodrome for VaD and AD.

METHODS

Serial Mini-Mental State Examination was administered at 3- to 6-month intervals, and neuroimaging was performed annually. Subtle cognitive dysfunctions were weighted and measured according to MCI criteria defined here. Subjects identified with MCI were then followed up for an additional 3.88+/-3.01 years. Diagnoses of VaD and AD were made according to established criteria.

RESULTS

During 3.72+/-2.94 years of follow-up of the original normative subjects, 73 of 291 (25.1%) developed MCI. Of the 27 subjects who developed VaD, 15 (55.6%) had prodromal MCI. Of these, two thirds were subclassified as having small-vessel dementia. The remaining 12 patients with VaD (44.4%) were diagnosed directly from a cognitively normal status without preceding MCI. These were predominantly multi-infarct or strategic-infarct dementia (66.7%). An additional 35 MCI subjects (47.9%) developed AD. Both VaD and AD diagnosed after MCI prodromes manifested similar spectral domains of cognitive impairments, which included memory, during their MCI stages.

CONCLUSIONS

In some VaD subtypes, particularly those caused by subcortical microvascular disease, dementia may be preceded by MCI, which has similar domains of cognitive impairment and a similar progressive course that may mimic AD.

Nonpharmacologic treatment of behavioral disturbance in dementia

This article provides an overview of the current literature on non-pharmacologic treatment of behavioral problems in patients with dementia, and offers practical guidelines for healthcare professionals interested in using this approach with their patients. Because effective treatment begins with accurate assessment, we provide a brief discussion of the state-of-the-art in assessment of behavioral problems. The article discusses current trends in clinical care along with specific strategies for treating and preventing some of the most common and debilitating behavioral problems of dementia patients: depression, agitation/aggression, wandering, and sleep disturbance. Because caregivers are essential informants and participants in patient care, we conclude by addressing the role of the caregiver in nonpharmacologic treatment.

The prevalence, diagnosis and treatment of depression in dementia patients in chronic care facilities in the last six months of life

OBJECTIVE

To assess the prevalence, diagnosis and treatment of depression among dementia patients and normal controls in chronic care facilities in the last six months of life.

METHOD

We reviewed perimortal data concerning dementia severity, depressive symptoms and diagnoses, and medication use for 279 dementia patients and 24 normal controls brought to autopsy through an Alzheimer's Disease Resource Center.

RESULTS

Major depression was highly prevalent among both dementia patients and normal controls in chronic care facilities in the last six months of life. This depression was under-diagnosed by physicians. Documentation of depressive symptoms by medical support staff has improved over time. However, physician diagnosis of depression has not improved. Recognition of depression was significantly lower for patients with severe dementia. Depression was under-treated in both dementia patients and normal controls, although treatment rates may be increasing. Anxiolytics and hypnotics were often used in lieu of, or in addition to, antidepressant therapy.

CONCLUSIONS

Major depression was highly prevalent in both dementia patients and normal controls, indicating that depression is an important issue for the elderly in the last six months of life irrespective of cognitive status. Under-diagnosis of depression may be an important clinical issue. As physician diagnosis of depression has not improved with time, further physician training and/or awareness initiatives may be warranted. Depression, a treatable cause of excess morbidity and mortality, was undertreated in all groups studied. However, treatment rates may be improving. The prevalent use of anxiolytics and hypnotics for depressed patients is problematic.

Depression, cognitive impairment and function in Alzheimer's disease

Depression is very common in patients with dementia but the relationship is very complex. Depression is regarded as a cause of excess disability in persons with dementia and contributes to their functional decline. The assessment of depression in dementia patients, however, has been difficult in that the validity of self-reported depression in patients with dementia has been questioned. This study was done to investigate whether self-reported depression by persons with dementia (using the GDS) is related to their functional abilities as rated by a family caregiver (using the IADL scale) above and beyond demographic variables. This study was conducted at the Detroit Satellite of the Michigan Alzheimer's Disease Research Center. There were 141 participants, 67% were African American and 33% were European American. Statistical analyses included a correlational and multiple regression approach to determine the predictive relationships of cognitive and depressive symptoms above and beyond the influence of demographic variables and cognition. The results of the study further support the notion that depression in dementia is significantly related to functional decline but, more importantly, that self-reported depression in patients with dementia can be valuable information in understanding patients' functioning.

Depressive syndromes and functional disability in dementia

The goals of this study were to assess (1) the prevalence of major and minor depression in Alzheimer's disease (AD), ischemic vascular dementia (IVD), and mixed dementia (AD/IVD); (2) demographic and clinical variables that may be associated with depression; and (3) the relationship between depression severity and the level of functional impairment and cognitive decline. Demographic variables, depression diagnoses, Mini-Mental State Examination scores, and Blessed Roth Dementia Rating Scale scores were compared in patients with AD (N = 582), IVD (N = 48), and mixed dementia (N = 61) using analysis of variance and linear regression models. Data were collected using standardized rating instruments at the time of the patients' initial evaluations at the University dementia clinics. The results were that (1) depression was related to lower education, (2) major depression was more prevalent in IVD compared to probable AD, and (3) functional impairment was greater in patients with minor or major depression compared to patients without depression. Our data suggest that the level of functional disability in dementia may be related to severity of depression. Additional studies are needed to validate our results and examine the contribution of additional neurobiologic factors to the pathophysiology of depression in dementia.

Assessment and management of behavioral disturbances in Alzheimer disease

This article provides an update and review of strategies for assessing and treating behavioral changes in patients with Alzheimer disease. It discusses the impact of behavioral disturbances on patients, presents guidelines for identifying and monitoring behavioral changes, and presents behavioral treatment approaches.