Differences between patient and family assessments of depression in Alzheimer's disease

Deep Learning of Speech Data for Early Detection of Alzheimer's Disease in the Elderly

BACKGROUND

Alzheimer's disease (AD) is the most common form of dementia, which makes the lives of patients and their families difficult for various reasons. Therefore, early detection of AD is crucial to alleviating the symptoms through medication and treatment.

OBJECTIVE

Given that AD strongly induces language disorders, this study aims to detect AD rapidly by analyzing the language characteristics.

MATERIALS AND METHODS

The mini-mental state examination for dementia screening (MMSE-DS), which is most commonly used in South Korean public health centers, is used to obtain negative answers based on the questionnaire. Among the acquired voices, significant questionnaires and answers are selected and converted into mel-frequency cepstral coefficient (MFCC)-based spectrogram images. After accumulating the significant answers, validated data augmentation was achieved using the Densenet121 model. Five deep learning models, Inception v3, VGG19, Xception, Resnet50, and Densenet121, were used to train and confirm the results.

RESULTS

Considering the amount of data, the results of the five-fold cross-validation are more significant than those of the hold-out method. Densenet121 exhibits a sensitivity of 0.9550, a specificity of 0.8333, and an accuracy of 0.9000 in a five-fold cross-validation to separate AD patients from the control group.

CONCLUSIONS

The potential for remote health care can be increased by simplifying the AD screening process. Furthermore, by facilitating remote health care, the proposed method can enhance the accessibility of AD screening and increase the rate of early AD detection.

Awareness of Psychiatric Symptoms in a Mixed Clinical Sample of Older Adults

OBJECTIVE

This study examined the neuropsychological correlates and impact on caregiver distress of reduced awareness of mood symptoms in patients with suspected neurodegenerative disease.

METHOD

Records from a clinical sample of older adults were examined (N = 940).

RESULTS

More than one-third of patient and caregiver ratings of mood symptoms did not agree (comparing patient and caregiver self-report measures); 27.9% of patients were unaware of depression (UoD) and 16.6% of patients were unaware of anxiety (UoA). The UoD group exhibited poorer verbal memory and executive abilities and the UoA group exhibited poorer verbal memory than those with preserved awareness. Unawareness was not associated with caregiver distress.

CONCLUSIONS

These findings highlight the importance of capturing informant report in clinical practice with older adults suspected of cognitive impairment. Unawareness of mood symptoms was related to memory dysfunction and-to a lesser extent-to executive abilities and may have implications for addressing patient and caregiver needs for disorders affecting these cognitive systems.

Development and Validation of a Short Version of the Cornell Scale for Depression in Dementia for Screening Residents in Nursing Homes

OBJECTIVES

To develop and validate a short version of the Cornell Scale for Depression in Dementia (CSDD-19) for routine detection of depression in nursing homes.

SETTING

Australian nursing homes.

METHODS

A series of cross-sectional studies were conducted involving: 1) descriptive analysis of pooled data from five nursing home studies that used the CSDD-19 (N = 671) to identify patterns of responses and missing data on individual CSDD items; 2) analysis of four of the five studies (N = 556) to assess CSDD-19 for unidimensionality, item fit, and differential item functioning using Rasch modeling to develop a shorter version, the CSDD-4; 3) validation of the CSDD-4 against the DSM-IV using the fifth study of 115 residents and through expert consultations; and 4) evaluation of the clinical utility of CSDD-4 using an independent cohort of 92 nursing home residents.

RESULTS

Four items from the original CSDD-19 were found to be most suitable for depression screening: anxiety, sadness, lack of reactivity to pleasant events, and irritability. The CSDD-4 highly correlated with the original scale (N = 474, r = 0.831, p < 0.001), with acceptable internal consistency (Cronbach's alpha = 0.70). At the cutoff score of less than 2, sensitivity and specificity of CSDD-4 were 81% and 51%, respectively, for the independent cohort (N = 92), of whom 50% had dementia. The CSDD-4 had an area under the curve (AUC) of 0.73 (z = 3.47, p < 0.001), which was compatible with the CSDD-19 (AUC = 0.69, z = 2.89, p < 0.01).

CONCLUSIONS

The CSDD-4 is valid for routine screening of depression in nursing homes. Its adoption is feasible and practical for nursing home staff, and may facilitate more comprehensive assessment and management of depression in nursing home residents.

Patient Mood and Instrumental Activities of Daily Living in Alzheimer Disease: Relationship Between Patient and Caregiver Reports

This retrospective study investigated the relationship between self-reports and caregiver perceptions of patients' depressive symptoms and the respective ability of these reports to predict instrumental activities of daily living (IADLs) beyond what is accounted for by cognitive abilities in 71 patients with mild Alzheimer disease. Patients completed the Geriatric Depression Scale-Short Form, and caregivers completed the Behavior Rating Scale for Dementia assessing their perception of patients' depressive symptoms. Caregivers also completed IADL items from the Alzheimer's Disease Cooperative Study Activities of Daily Living Inventory. Cognitive measures included the Mini-Mental State Examination, Logical Memory from the Wechsler Memory Scale III, and Trail Making Test, Part B. The relationship between self-reported depressive symptoms and caregiver report of patients' depressive symptoms showed a trend toward significance (r = .22, P = .06). Measures of depressive symptoms significantly predicted 12.5% of the variance in IADLs performance, beyond that accounted for by patient demographics and cognitive functioning. Interestingly, patients' reports, rather than caregivers', were particularly useful in this prediction.

The Alzheimer's disease cooperative study prevention instrument project: longitudinal outcome of behavioral measures as predictors of cognitive decline

Background/Methods

The Alzheimer's Disease Cooperative Study Prevention Instrument Project is a longitudinal study that recruited 644 cognitively healthy older subjects (aged between 75 and 93 years, 58% women) at baseline and evaluated their cognitive change over 4 years. The study was structured like a clinical trial to anticipate a prevention trial and to determine the performance of novel trial instruments in a longitudinal non-interventional trial framework. Behavioral symptoms were assessed at baseline.

Results

The existence of participant-reported behavioral symptoms at baseline predicted conversion to Clinical Dementia Rating scale score ≥0.5 over the 4-year period.

Conclusions

The results imply that early anxiety and depression may be harbingers of future cognitive decline, and that patients exhibiting such symptoms, even in the absence of co-occurring cognitive symptoms, should be closely followed over time.

Comparing reports from hip-fracture patients and their proxies: implications on evaluating sex differences in disability and depressive symptoms

OBJECTIVE

This study compared sex differences in disability and depressive symptoms using reports from hip fracture patients and their proxies.

METHOD

Hip fracture patients (49 men, 183 women) aged ≥65 years and proxies were interviewed 1 year postfracture. Outcomes were Center for Epidemiological Studies Depression (CES-D) and number of dependencies in performing activities of daily living and instrumental activities of daily living.

RESULTS

Mean ADL sex differences (men minus women) were 0.40 (p = .37) using proxy reports and 0.70 (p = .08) using patient self-reports. Mean CES-D sex differences were -3.60 (p = .02) using proxy reports and -1.26 (p = .38) using patient self-reports. Discrepancies between patients and proxies were smallest for proxies who have lived with the patient ≥ 1 year.

DISCUSSION

Patients and proxies produced conflicting conclusions about sex differences. Results suggest that ideal proxies to recruit are those who have been cohabitating with the patients for an extended length of time.

Perceptions of depression among dementia caregivers: findings from the CATIE-AD trial

OBJECTIVE

For patients with Alzheimer's disease complicated by behavioral disturbances, to use single questions about perceived depression and assess patient and caregiver accuracy in recognizing patient depression.

METHODS

Cross-sectional interviews from the Clinical Antipsychotic Trials of Intervention Effectiveness-Alzheimer's Disease (CATIE-AD). Patients were asked 'Do you believe you are depressed?' Caregivers were asked 'Do you believe the patient is depressed?' and 'Do you believe you (caregiver) are depressed?' These responses were compared to the patient's score on the Cornell Scale for Depression in Dementia (CSDD), and to the caregiver's score on the Beck Depression Inventory (BDI) using screening test characteristics.

RESULTS

Two hundred fifty-seven total patient/caregiver pairs were evaluated. Patients had a mean age of 78 years, were mainly female, white, and had a mean Mini-Mental State Examination Score of 15. Caregivers were on average 63 years old, and were mostly spouses or children. 37% of patients had depression (CSDD ≥ 12). Patients recognized their own depression with a sensitivity of 0.26 (CI: 0.18, 0.37) and specificity of 0.85 (0.79, 0.90). Caregivers' accuracy in recognizing depression in the patient revealed a sensitivity of 0.65 (C.I.: 0.55, 0.75) and specificity of 0.58 (CI: 0.50, 0.66). Twelve per cent of caregivers were depressed, and caregiver burden was associated with patient depression.

CONCLUSION

Clinically significant depression was common, and asking a single question to the patient about depression failed to detect most cases. Caregivers identified two-thirds of patient depression when asked this one question. Caregiver depression and perceived burden were associated with patient depression.

Behavioural symptoms in patients with Alzheimer's disease and their association with cognitive impairment

Background

Behavioural and psychological symptoms of dementia (BPSD) are non-cognitive symptoms commonly associated to Alzheimer's disease (AD). The characterization of the clinical profile of AD patients might help to better understand disease evolution and to improve diagnosis and treatment. Thus, the aim of the present study is to describe the clinical profile of AD patients, and to correlate the presence of BPSD with the severity of the disease.

Methods

A cross-sectional, observational and multicenter study was conducted at 115 centres in Spain. Patients suffering from AD with higher and lower BPSD scores (ADAS-Noncog score 26-50 and ≤25, respectively) were included. Demographic and clinical data were collected, and dementia severity was assessed by the Mini Mental State Examination (MMSE) [mild 27-21, moderate 20-11, severe ≤10]. The use of ADAS-Noncog in clinical practice was also explored.

Results

A total of 1014 patients (463 with higher and 551 with lower BPSD scores) were included (mean age 77 ± 7 years, 65% women). Almost all patients (90%) had BPSD at inclusion, 17% of which reported psychotic outbreaks. The most prevalent symptoms were lack of concentration (56%), tremors (56%), depression (44%), lack of cooperation (36%), and delusions (32%). Patients with higher BPSD scores showed a significantly higher prevalence of psychotic symptoms (delusions, hallucinations, and delirium) and tremors, while emotional symptoms (tearfulness and apathy) predominated in patients with lower BPSD scores. MMSE and ADAS-Noncog scores were negatively associated (p = 0.0284), suggesting a correlation between cognitive impairment and BPSD. Lack of concentration and appetite change significantly correlated with MMSE (p = 0.0472 and p = 0.0346, respectively). Rivastigmine and donepezil were the first choice therapies in mild to moderate dementia. ADAS-Noncog was generally considered better or similar to other scales (82%), and 68% of the investigators were willing to use it in the future.

Conclusions

Our study shows that patients with AD have a high prevalence of noncognitive symptoms, and that cognitive impairment and BPSD are correlated. Therefore, ADAS-Noncog is a useful evaluation tool.

Psychotic and behavioural symptoms in a population-based sample of the very elderly subjects

OBJECTIVE

The aim was to elucidate the relationship between psychotic and behavioural symptoms in the elderly.

METHOD

A representative sample of 85 year old subjects living in Gothenburg, Sweden (n = 451) was assessed with neuropsychiatric examinations, key informant interviews and record reviews.

RESULTS

Fourteen percent of these very elderly subjects had paranoid symptoms with concomitant anxious agitation and/or irritability/anger. Hallucinations and paranoid symptoms were both associated with a pattern of behavioural symptoms including both anxious agitation and irritability/anger simultaneously in both demented [hallucinations, Odds ratio (OR) 2.8, Confidence interval (CI) 1.2-6.7, paranoid symptoms OR 5.6 CI 2.2-14.2] and non-demented (hallucinations OR 3.2 CI 1.2-8.3, paranoid symptoms OR 4.8 CI 2.0-11.8).

CONCLUSION

Psychotic symptoms are associated with behavioural symptoms regardless of dementia status. Since these symptoms lead to decreased ability to function in daily life and increased caregiver burden, it is important for health professionals to identify and treat these symptoms also in non-demented.

An examination of the "gold standard" diagnosis of major depression in aged-care settings

OBJECTIVES

Individual clinical interviews are typically viewed as the "gold standard" when diagnosing major depressive disorder (MDD) and when examining the validity of self-rated questionnaires. However, this approach may be problematic with older people, who are known to underreport depressive symptomatology. This study examined the effect of including an informant interview on prevalence estimations of MDD in an aged-care sample.

DESIGN

The results of an individual clinical interview for MDD were compared with those obtained when an informant interview was incorporated into the assessment. Results from each diagnostic approach were compared with scores on a self-rated depression instrument.

SETTING

Low-level aged-care residential facilities in Melbourne (equivalent to "residential homes," "homes for the elderly," or "assisted living facilities" in other countries).

PARTICIPANTS

One hundred and sixty-eight aged-care residents (mean age: 84.68 years; SD: 6.16 years) with normal cognitive functioning.

MEASUREMENTS

Individual clinical interviews were conducted using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I Disorders. This interview was modified for use with staff informants. Self-reported depression was measured using the Geriatric Depression Scale-15 (GDS-15).

RESULTS

The estimated point prevalence of MDD rose from 16% to 22% by including an informant clinical interview in the diagnostic procedure. Overall, 27% of depressed residents failed to disclose symptoms in the clinical interview. The concordance of the GDS-15 with a diagnosis of MDD was substantially lower when an informant source was included in the diagnostic procedure.

CONCLUSION

Individual interviews and self-report questionnaires may be insufficient to detect depression among older adults. This study supports the use of an informant interview as an adjunct when diagnosing MDD among cognitively intact aged-care residents.

Self-, collateral- and clinician assessment of depression in persons with cognitive impairment

OBJECTIVES

This investigation examined the associations between self-reports, collateral-source reports and a clinician's diagnosis of depression in persons with cognitive impairment.

METHOD

Responses on the Geriatric Depression Scale - 15 (GDS-15) from 162 participants with a diagnosis of Mild Cognitive Impairment (n = 78) or Alzheimer's Dementia and a Mini-Mental State score >or=15 (n = 84) were compared with both their collateral sources' report on either the Neuropsychiatric Inventory Questionnaire (n = 93) and/or the collateral-source GDS-15 (n = 67), or a clinician's diagnosis of Major Depression (MD).

RESULTS

Significant differences were seen between self- versus collateral-source reports of depression in these participants. Participants' reports of loss of interest (anhedonia) significantly increased the odds of disagreement with their collateral sources (OR = 3.78, 95% CI: 1.3-11.2) while reports of negative cognitions significantly decreased the odds of such a disagreement (OR = 0.31, 95% CI: 0.1-0.9). The symptom of anhedonia also showed the strongest association with the clinician's diagnosis of MD.

CONCLUSION

A motivational symptom like loss of interest was seen to play an important role in depression experienced by those with cognitive impairment.

Diagnosing depression in Alzheimer disease with the national institute of mental health provisional criteria

OBJECTIVE

To compare the rates of depression in Alzheimer Disease (AD) determined using National Institute of Mental Health (NIMH) provisional criteria for depression in AD (NIMH-dAD) to those determined using other established depression assessment tools.

DESIGN

Descriptive longitudinal cohort study.

SETTING

The Alzheimer's Disease Research Centers of California.

PARTICIPANTS

A cohort of 101 patients meeting NINDS-ADRDA criteria for possible/probable AD, intentionally selected to increase the frequency of depression at baseline.

MEASUREMENTS

Depression was diagnosed at baseline and after 3 months using NIMH-dAD criteria and the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) Axis I Disorders. Depressive symptoms also were assessed with the Cornell Scale for Depression in Dementia (CSDD), the Geriatric Depression Scale (GDS), and the Neuropsychiatric Inventory Questionnaire.

RESULTS

The baseline frequency of depression using NIMH-dAD criteria (44%) was higher than that obtained using DSM-IV criteria for major depression (14%; Z = -5.50, df = 101, p <0.001) and major or minor depression (36%; Z = -2.86, df = 101, p = 0.021) or using established cut-offs for the CSDD (30%; Z = -2.86, df = 101, p = 0.004) or GDS (33%; Z = -2.04, df = 101, p = 0.041). The NIMH-dAD criteria correctly identified all patients meeting DSM-IV criteria for major depression, and correlated well with DSM-IV criteria for major or minor depression (kappa = 0.753, p <0.001), exhibiting 94% sensitivity and 85% specificity. The higher rates of depression found with NIMH-dAD criteria derived primarily from its less stringent requirements for the frequency and duration of symptoms. Remission rates at 3 months were similar across instruments.

CONCLUSIONS

The NIMH-dAD criteria identify a greater proportion of AD patients as depressed than several other established tools.

Contribution of depression to cognitive impairment and dementia in older adults

BACKGROUND

The objective of this review is to provide information for clinicians regarding current research and opinions on the association of depression to conditions of cognitive impairment and dementia. We also intend to integrate this current research and thinking into strategies for the assessment and treatment of depression in the context of cognitive impairment.

REVIEW SUMMARY

Depression is highly prevalent in mild cognitive impairment and most dementias. It may be a risk factor for the subsequent development of dementia and in some conditions may be a prodromal symptom. It is important to detect and effectively treat depression because the comorbidity of depression and cognitive impairment is associated with greater cognitive and functional decline and higher rates of institutionalization. Depression often can be differentiated from Alzheimer disease and other dementias based on characteristics of clinical history and presentation. Screening of depression and cognitive impairment will help characterize the presence and severity of these conditions, but limitations in screening approaches may necessitate comprehensive assessment in complex cases where differential diagnosis is important to treatment planning.

CONCLUSION

Although depression and cognitive impairment are important issues in the treatment of older adults, there are particular risks when they occur together. Appropriate assessment and screening can help guide the clinician to appropriate and timely interventions. Pharmacologic and nonpharmacologic treatment approaches are both efficacious in reducing depression in cognitive impairment and dementia.

Comparison of three rating scales as outcome measures for treatment trials of depression in Alzheimer disease: findings from DIADS

CONTEXT

Major depression affects about 25% of patients with Alzheimer's disease (AD) and has serious adverse consequences for patients as well as caregivers. Studies of treatments for depression in AD, like most treatment studies, depend on the ability of the scales used to measure outcome to detect a difference between the effects of treatment and control, particularly in trials conducted over waves.

OBJECTIVE

To compare the ability of three depression scales, and some of their subscales, to detect the difference in the effects of drug (treatment) and placebo (control).

DESIGN

Comparison of three scales of depression in terms of percent variance explained as indicated by the adjusted or partial eta-squared for the effect of drug versus placebo, controlling for baseline depression, in a randomized, placebo-controlled, parallel, 12-week, clinical trial of sertraline for the treatment of depression with AD.

SETTING

University outpatient clinic.

PARTICIPANTS

Forty-four patients with probable Alzheimer's disease and Major Depressive Episode.

OUTCOME MEASURES

The Cornell Scale for Depression in Dementia (CSDD), the Hamilton Depression Rating Scale (HDRS), and the Neuropsychiatric-Inventory Mood Domains (NPI-M).

RESULTS

Examination of the treatment effects as indicated by the partial eta-squared's for each scale at each wave, revealed a slight, but not significant, advantage for the use of the CSDD over the HDRS, and a significant advantage for the use of either of these over the NPI-M. Treatment effects, as reflected in the partial eta-squared's computed for the subscales at each wave, were significant for all four subscales, and were largest for the CSDD 'mood' subscale although they were not significantly greater than for the other subscales.

CONCLUSIONS

The CSDD, and particularly its mood subscale, appears to be more sensitive than the HDRS, it's subscales or the NPI-M, for comparing drug to placebo in treating major depression in AD patients. Treatment effects as reflected in the partial eta-squared's were largest on the CSDD mood subscale and increased over time. The pattern for the other subscales was non-monotonic over waves and resembled the pattern for the entire scale. Perhaps combining the CSDD two subscales obscures the treatment effects for the separate subscales.

A percepção de qualidade de vida do idoso avaliada por si próprio e pelo cuidador

O objetivo deste estudo foi investigar a relação entre a percepção de qualidade de vida (QV) do idoso por ele próprio e por seu cuidador. Assim, 27 pares de idosos-e-cuidadores foram avaliados. Os idosos foram convidados a responder sobre condições sociodemográficas, QV (WHOQOL-100) e sintomatologia depressiva (BDI). Os cuidadores responderam os mesmos itens com relação a sua própria pessoa e também o WHOQOL-100 adaptado. Os dados mostraram uma tendência de o cuidador apresentar pior percepção de QV do idoso do que o próprio idoso cuidado. Apesar disso, observou-se concordância nos resultados de QV percebidos pelo idoso e na opinião do cuidador sobre a QV do idoso nos domínios físico, nível de independência, meio ambiente e espiritualidade/religião. A intensidade de depressão do idoso exerceu forte influência tanto na sua própria percepção de QV quanto na percepção do cuidador.

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.

Concordance of Proxy-Perceived Change and Measured Change in Multiple Domains of Function in Older Persons

OBJECTIVES

To compare proxy perceptions about change over 6 months in physical, instrumental, affective, and cognitive functioning of older persons with computed change in patient self-report and performance and patient's own perceptions about change.

DESIGN

Prospective study.

SETTING

Recovery from hip fracture that occurred in community-dwelling persons in Baltimore, Maryland, in 1990-91. The recovery from the sixth to the 12th month postfracture was observed.

PARTICIPANTS

One hundred forty-one hip fracture patients aged 65 and older and a self-designated proxy for each.

MEASUREMENTS

For specific tasks of physical and instrumental functioning, proxy perception of change over the previous 6 months asked in the 12th month postfracture was compared with change in criterion measures (subject self-report and observed performance) from the sixth to the 12th month postfracture. For global change over the previous 6 months in each area of functioning, proxy perception was compared with the subject's own perception in the 12th month postfracture.

RESULTS

Agreement between proxy perceptions of change and change in criterion measures was poor. There was a general pattern for proxies to overstate improvement and understate deterioration in comparison with change observed in criterion measures for specific tasks of physical and instrumental functioning. Proxies' global perceptions reported subjects improving less and deteriorating more than patients' own perceptions.

CONCLUSION

Proxy perceptions about task-specific and global changes in subjects' functional health over a short period of time are systematically different from patient report and observed performance.

Depression in Alzheimer's disease: heterogeneity and related issues

Several studies have demonstrated that the great majority of Alzheimer's disease (AD) patients suffer "noncognitive" neuropsychiatric symptoms. Depression is one of the most frequent neuropsychiatric comorbidities of AD. Affecting up to 50% of AD patients, depression in AD is associated with serious negative consequences for patients and their caregivers. Yet available studies on the natural course, etiology, and treatment of depression in AD have been few and equivocal. Heterogeneity in research methodology and etiology of depression in AD might have contributed to inconsistent findings across studies. Recently, the National Institute of Mental Health (NIMH) convened the Depression of Alzheimer's Disease Workgroup, which proposed provisional diagnostic criteria for depression of Alzheimer's Disease (NIMH-dAD). These criteria may provide a framework for future studies to clarify the unresolved issues in nosology, etiology, and treatment of depression in AD. A longitudinal cohort study of depression in incident AD cases may provide further syndrome refinement that would facilitate investigation of the etiology and treatment of depression in AD.

Evolution of depressive symptoms in Alzheimer disease: one-year follow-up

The current longitudinal study analyzes the natural course of depressive symptoms in patients with Alzheimer disease (AD). The goals were to identify the clinical and sociodemographic variables related to depressive symptoms, to assess the effect of depressive symptoms on the course of cognitive and functional impairment and on associated neuropsychiatric disorders, and to identify which factors are associated with remission, persistence, and emergence of depressive symptoms at 12 months. A sample of 150 patients with mild or moderate severity was assessed at baseline and at 12 months using the neuropsychologic battery Cambridge Cognitive Examination. The Neuropsychiatric Inventory and Rapid Disability Rating Scale were administered to the caregiver. Prevalence, persistence, and emergence of depressive symptoms at baseline were 51%, 55%, and 20%, respectively. Remission of depressive symptoms at 12 months leads to a decreased frequency of other noncognitive disorders and to a slight improvement in the assessment of global function. The presence of depressive symptoms does not affect the course of cognitive impairment at 12 months, and a psychiatric history of the patient and the number of depressive symptoms at baseline are risk factors for the emergence and persistence of depressive symptoms at 12 months.

Family and professional caregivers' ratings of dementia symptoms and activities of daily living of day care patients: do differences change over time?

The purpose of this study was to compare ratings of patients' carried out by professional and family caregivers. These patients were attending rehabilitative geriatric and gerontopsychiatric day care centres, they were about 77 years old, 93% had dementia, and each had an average of 4.7 diseases. Eighty percent of the family caregivers were female, and 60% were children of the patients. Staff raters of the day care units were trained professionals. Data were collected at two measurement times: T1 took place during the first ten days of service use; T2 was conducted six months later. Activities of daily living (ADL) and Memory and Behaviour Problems (MBPC) were investigated. Family caregivers noted significantly more deficits on the ADL scale, and significantly more problems on the MBPC scale. These differences increased when subjective burden of the family caregiver was high. The longitudinal results showed that these differences in ADL and MBPC ratings remained remarkably stable, although there was an increase in deficit ratings in both groups.

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.

Neurological changes and emotional functioning in adults with Down Syndrome

This study was designed to examine emotional changes in adults with Down Syndrome (DS) over time and whether changes in these psychological variables were associated with brain atrophy on MRI scan and the presence of pathological reflexes on the neurological examination. Participants were 26 adults with DS and their caregivers. Caregivers completed a measure of emotional functioning about individuals with DS at two different time points (1 year apart). Levels of cognitive functioning were measured and neurological and MRI examinations were performed on all subjects at initial testing. Significant group effect separated those with and without pathological findings on MRI and neurological exam across three different scales: depression, indifference, and pragmatic language functioning. Problems of poor pragmatic language functioning appeared later in the course of suspected Alzheimer's disease (AD), as demonstrated by a significant group effect at time 2, but not at initial testing. In these subjects, the primary emotional change was a decline in social discourse (e.g. conversational style, literal understanding, verbal expression in social contexts). These emotional levels were stable over time, regardless of degree of cognitive decline. Specific emotional changes occur during the course of AD which were associated with abnormal findings from MRI and from neurological examination. These results, along with abnormalities in brain imaging and the presence of pathological reflexes, suggested that frontal lobe dysfunction is likely to be an early manifestation of Alzheimer's Disease in Down Syndrome.

Clinically significant depressive symptoms and very mild to mild dementia of the Alzheimer type

OBJECTIVE

To compare depressive symptoms reported by persons with very mild or mild dementia of the Alzheimer type (DAT) with those reported for the person by a collateral source.

DESIGN

Cross-sectional evaluation.

SETTING

Washington University Alzheimer's Disease Research Center.

PARTICIPANTS

Consecutive series of elderly volunteers (n = 156) enrolled in longitudinal studies with a Clinical Dementia Rating (CDR) of 0.5 (very mild) or 1 (mild). Twenty-one per cent (n = 33) exhibited clinically significant depressive symptoms for which treatment was recommended.

MAIN OUTCOME MEASURES

Presence and frequency of DSM-IV depressive symptoms within the last year and last month reported by the participant or collateral source as ascertained by clinical examination and structured interviews.

RESULTS

Collateral source information is essential in diagnosing clinically significant depressive symptoms. The Geriatric Depression Scale scores correlate with participant information only and therefore may substantially underestimate depression. Depressive symptoms fluctuate in individuals with DAT. The most consistent depressive symptoms are depressed mood, fatigue and indecision.

CONCLUSIONS

Clinically significant depressive symptoms may be common in individuals with very mild or mild DAT, although they may fluctuate. Information from both a knowledgeable collateral source and the participant is important for detection of depressive symptoms.

The use of proxy respondents in studies of older adults: lessons, challenges, and opportunities

OBJECTIVE

Proxies play a critical role as sources of health information for older persons with cognitive impairment and other chronic debilitating conditions. This paper reviews the validity of proxy responses for people older than age 60 in the following areas: functioning, physical and mental health, cognition, medical care utilization, and preferences for types of care and health states.

DESIGN

A Medline review identified 24 clinical studies from 1990 to 1999 that use proxy data as a source of information about older adults.

RESULTS

In general, studies report fairly good agreement between subjects and proxies in assessments of functioning, physical health, and cognitive status, and fair-to-poor agreement in assessments of psychological well-being. Proxies tend to describe more impairment in functioning and emotional well-being, relative to subjects, a pattern that is particularly marked among persons with cognitive impairment. In addition, proxies who report more caregiver responsibilities and subjective stress from caregiver duties provide more negative assessments of subjects' health and well-being.

CONCLUSIONS

Findings tend to support the use of proxy ratings among older adults in many areas but not all when self-reports are not feasible. There is a need for more evaluation of proxy data in relation to other measures, such as performance assessments, medical records, and claims data, which may be less subject to respondent biases.

[Expressions of depression in Alzheimer's disease. The current scientific debate]

This overview analyses findings coming from researches that considered the interaction between depression and Alzheimer's disease (AD).

METHOD

Information was collected from the Medline database and from a reasoned manual analysis of the published studies.

RESULTS

The prevalence of depressive symptoms in patients with AD is elevated (40-50%). The role of depression in the pathogenesis of AD (independent, prodromal symptom, factor of risk) still must be defined. Data on family history of depression suggest that AD could act as stimulus triggering depression from a basis of a genetic vulnerability. From a biological point of view the onset of depression could derive from an unbalance between cholinergic and noradrenergic systems. Psychological understanding sees depression as a reaction of mourning for the cognitive deficit. Current diagnostic instruments validated on patients with AD constitute a good aid for the clinician and the researcher. The identification of depression coexisting with AD is difficult, in absence of clear affective symptoms, since the cognitive, psychomotor and vegetative symptoms belong both to depression and to AD. The affective disorders most frequently reported are major depression and dysthymia. The use of antidepressant drugs with the lowest anticholinergic profile is strongly recommended. Good results have been obtained also using various psychotherapeutic interventions adapted for dementia sufferers.

CONCLUSIONS

The current scientific debate is based on information still limited and sparse. Future analyses should consider a better definition of the hypotheses related to psychopathology in AD, a standardised definition of cases and selection procedures and a prospective longitudinal design.

Depressive disorders in Chinese patients with Alzheimer's disease

OBJECTIVE

The present study was to investigate the prevalence and potential risk factors of depressive disorders in Chinese patients with Alzheimer's disease (AD).

METHOD

A series of consecutive AD patients from the Memory Disorders Clinic of the Veterans General Hospital, Taipei were studied. Psychiatric diagnosis was made according to DSM-III-R criteria with the use of the Structured Clinical Interview for DSM-III-R (SCID). The Chinese version of the Cognitive Abilities Screening Instrument (CASI) and the Hamilton Depression Rating Scale (HDRS) were also applied. Primary caregivers were interviewed for the Clinical Dementia Rating (CDR) scale, the Barthel Index and the Alzheimer's Deficit Scale (ADS).

RESULTS

Among 141 AD patients, seven (5.0%) were diagnosed with major depression, 11 (7.8%) with dysthymia and five (3.5%) with depressive disorder not otherwise specified. Women were at elevated risk for depressive disorders and had more severe symptoms of depression.

CONCLUSIONS

The prevalence of depressive disorders among Chinese AD patients is in the middle of the range of western findings. The risk factor for depression is female gender.

Noncognitive disturbances in Alzheimer's disease: frequency, longitudinal course, and relationship to cognitive symptoms

OBJECTIVE

To investigate the frequency and longitudinal course of symptoms of depression, agitation, and psychosis in a longitudinally studied sample of patients with Alzheimer's disease (AD).

DESIGN

Longitudinal study of AD patients with follow-up assessments at 6-month intervals for an average of more than 3 years.

SETTING

Alzheimer's Disease Research Center of the Mount Sinai Medical Center and the Bronx VA Medical Center, New York.

PARTICIPANTS

A total of 153 AD patients.

MEASUREMENTS

Blessed Test of Information, Memory and Concentration (BIMC) and the Alzheimer's Disease Assessment Scale cognitive (ADAS-Cog) and noncognitive (ADAS-NC) subscales.

RESULTS

At entry into the study, more than 90% of patients had a behavioral disturbance that was rated as mild or worse on one of the 10 ADAS noncognitive items; and 40% had at least one rating that was moderate or severe. Correlational analyses indicated that, with the exception of the two mood-related items, noncognitive symptoms on the ADAS were not highly correlated with one another. Only one of the noncognitive items, concentration, was strongly correlated with the severity of cognitive impairment. On average, patients showed progressively worse cognitive functioning over time as measured both by the ADAS-Cog and the BIMC. The mean severity of noncognitive symptoms did not change during the course of a 5-year follow up. The severity of behavioral disturbance at any one evaluation was negatively correlated with change in behavior during the next 6 months and was not correlated with cognitive decline.

CONCLUSION

Mild behavioral disturbances are common, whereas moderate to severe behavioral symptoms are less frequent in this population of AD patients. Disturbances in mood and manifestations of agitation and psychotic symptoms are not closely related to one another and show little progressive worsening over time. Rather, they tend to be episodic such that increasing severity at one time is usually followed by improvement later. Concentration problems are a manifestation of cognitive dysfunction rather than behavioral disturbance in AD. Implications of these results for treatment of noncognitive disturbances in AD are discussed.

Criterion-related validity of the Geriatric Depression Scale in Alzheimer's disease

The effect of cognitive impairment on the criterion-related validity of the self-report Geriatric Depression Scale (GDS) was investigated in community-dwelling older adults. The GDS was administered to subjects with Alzheimer's disease (AD; n = 715) and normal cognitive function (NC; n = 93). The criteria consisted of the diagnosis of major depressive disorder and the total score on Hamilton Rating Scale for Depression, each derived from structured interview with a collateral informant to circumvent the effect of cognitive impairment on criterion measurement. Agreement between the GDS and both criteria was substantially attenuated in AD relative to NC subjects, differences primarily reflecting a lower than expected rate of item endorsement on the GDS in AD. A decrement in GDS validity coefficients was measurable across a broad range of cognitive impairment, suggesting limited utility of the scale in AD.

Depression in a long-term care facility: clinical features and discordance between nursing assessment and patient interviews

OBJECTIVE

Nurses commonly observe more depression than is diagnosed and treated in nursing homes. Accordingly, we aimed to describe the clinical features of untreated nursing home residents whom nurses identify as depressed and to compare nurse ratings of depressed nursing home residents with ratings from direct interviews and patient self-reports.

DESIGN

Cross-sectional survey followed by semi-structured diagnostic interviews of depressed patients and their nurses.

SETTING

A large academic, multi-level, long-term care facility.

PARTICIPANTS

Thirty-seven patients aged 74-99 (mean age 88.4) whom nurses identified as having daily symptoms of depression. Subjects had Mini-Mental State Exam (MMSE) scores > 10 (mean score 21.2), were not acutely or terminally ill, and were able to participate in an interview.

MEASUREMENTS

DSM-III-R mood diagnoses and separate ratings of interviews with nurses and patients using the Cornell Scale for Depression.

RESULTS

Nurses observed daily symptoms of depression in 110 of 495 (22%) long-term care residents on units not reserved for advanced dementia. Of these 110 patients, 58 (53%) were not receiving antidepressants. Of 37 patients eligible for interviews, nine met criteria for major depression, 20 met criteria for another non-major depression diagnosis, and eight did not have a diagnosable mood disorder. Cornell scale ratings derived exclusively from interviews of nurses were similar across the three diagnostic groups (12.5, 9.9, and 9.5, respectively; P = .31; mean 10.5), whereas Cornell scale ratings from patient interviews differed among groups (15.9, 6.9, and 4.1, respectively; P < .001; mean 8.4). Correlation between nurse Cornell ratings and patient Cornell ratings was poor (r = .27), especially for patients with non-major forms of depression (r = -.20). MMSE and Cumulative Illness Rating Scale (CIRS-G) scores were similar in the three groups.

CONCLUSIONS

Nurses frequently observed symptoms of depression in a long-term care setting, and many symptomatic patients were not being treated with antidepressants. In these patients, nurse-derived symptom ratings did not vary across DSM-III-R diagnostic categories and correlated poorly with ratings from direct patient interviews. These findings suggest that nurse caregivers may contribute important diagnostic information about non-major depression and raise questions about the application of standard diagnostic categories to late-life depression in the nursing home.

Depression in Alzheimer's disease patients: caregivers as surrogate reporters

OBJECTIVE

To evaluate the use of caregivers as surrogate reporters of depressive symptoms in Alzheimer's disease (AD) patients on five depression measures.

DESIGN

Scale characteristics, including means, ranges, internal consistency, sensitivity, and item content of modified self-report questionnaire and interview depression measures were compared.

PARTICIPANTS

Seventy-six patients, diagnosed with both depression and AD, and their family caregivers participated in this investigation. All subjects were community-residing participants in a treatment outcome investigation of behavioral treatment for depression.

MEASUREMENTS

A Schedule for Affective Disorders and Schizophrenia (SADS) interview was completed on all subjects to establish a diagnosis of depression. Caregivers then completed three additional questionnaire measures about their patient: the Beck Depression Inventory (BDI), the Geriatric Depression Scale (GDS), and the Center for Epidemiological Studies-Depression Scale (CESD), all modified to provide a surrogate report of their patient's depressive symptoms. In addition, two interview measures were completed based on interviews with the caregiver and patient: the Hamilton Depression Rating Scale (HDRS) and the Cornell Scale for Depression in Dementia (CSDD).

RESULTS

Mean scores for this sample were above the recommended cutoff score for mild levels of depression on all measures. Coefficient alpha levels were comparable to levels reported for the traditional self-report formats. Sensitivity varied among the measures, with the CSDD most sensitive and the HDRS least sensitive. Item content varied across measures, particularly between questionnaire and interview measures.

CONCLUSIONS

Based on these results, it appears that caregivers are able to act as surrogate reporters of depression in AD patients. The modification of self-report questionnaires did not decrease their internal consistency, and they remained highly correlated with each other, supporting their validity when used in this manner. A two-step process of evaluating AD patients for depression is recommended: first, a surrogate report questionnaire completed by caregivers to screen patients, eliminating those who are unlikely to be depressed, and then a more extensive interview with those patients-and their caregivers- who appear likely to be depressed.

Prevalence of depression in Alzheimer's disease and validity of Research Diagnostic Criteria

This study was undertaken to estimate the point-prevalence of Research Diagnostic Criteria (RDC) depressive syndromes in Alzheimer's disease (AD) and to evaluate the validity of existing and potential alternative diagnostic criteria for major depression in the presence of probable AD. Twenty-six subjects with probable AD of mild to moderate severity and their caregivers were interviewed to estimate the prevalence of RDC depressive syndromes. For the evaluation of the validity of RDC for major depression, an additional 8 probable-AD subjects with suspected depression were added to the sample. Sensitivity, specificity, and correlation with diagnosis of RDC major depression were calculated for each diagnostic criterion, and existing major depressive criteria were compared to potential alternative criteria currently used for RDC minor depression. Of the subjects in our prevalence sample, 15.4% were found to have major depression; 23.1%, minor depression; and 11.5%, intermittent depression. In our validation sample, two criteria for major depression, self-reproach/guilt and thinking/concentration difficulty, were weakly associated with the final diagnosis of major depression because of poor sensitivity or specificity. In contrast, three possible alternative criteria were significantly associated with the diagnosis of major depression and showed high sensitivity and specificity. These included nonverbal manifestations of depression, irritability/complaining, and demandingness/dependency. We conclude that RDC depressive syndromes are common in probable AD of mild to moderate severity. In the presence of AD, the validity of some existing major depressive criteria may be limited in comparison to several potential alternative criteria because of relatively poor sensitivity and/or specificity.

Depression in Alzheimer's disease: receiver operating characteristic analysis of the Cornell Scale for Depression in Dementia and the Hamilton Depression Scale

This study compares the performance of the Cornell Scale for Depression in Dementia (CSDD) and the Hamilton Depression Scale (HDS) in detecting Research Diagnostic Criteria (RDC) major depression in subjects with mild-to-moderate Alzheimer's disease (AD). Thirty-four subjects with this diagnosis and their caregivers were interviewed. The senior author conducted a diagnostic interview to determine RDC diagnosis. An investigator, blind to diagnosis, obtained demographic information and administered the Mini Mental State Examination, Global Deterioration Scale, CSDD and HDS. For each depression scale, the correlation with the RDC diagnosis of major depression was calculated, as were the sensitivity and specificity at various cutoff scores. Nonparametric receiver operating characteristic analysis was used to compare the performance of the two scales. The area under the receiver operating characteristic curve was .91 for the CSDD and .87 for the HDS. This differed from chance to a highly significant degree for both the CSDD and the HDS but the difference between the two scales was not statistically significant. Although the precision of the present study is limited by the small sample size, a cutpoint of 7 provided reasonable performance for both the CSDD and the HDS, yielding a sensitivity of .90 for both scales and a specificity of .75 for the CSDD and 0.63 for the HDS. Although the CSDD and the HDS are rating scales rather than diagnostic instruments, receiver operating characteristic analysis indicates that both demonstrate statistically significant discriminating ability for RDC major depression in mild to moderate, probable AD.(ABSTRACT TRUNCATED AT 250 WORDS)

The Use of the Hamilton Rating Scale for Depression in Elderly Patients With Cognitive Impairment and Physical Illness

The authors performed a prospective study to assess the impact of cognitive impairment and medical burden on the Hamilton Ratingh Scale for Depression (Ham-D) scores in older psychiatric inpatients. Over 1 year, all patients admitted to an acute-care geriatric psychiatry unit were assessed with an instrument that includes an anchored version of the 17-uten Ham-D. Ham-D scores of 72 patients who met DSM-III-R criteria for a major depressive episode were compared with the scores of 31 patients who did not. The scores of a depressed and nondepressed patients were significantly different on admission but not at discharge. By contrast, the Ham-D scores of 11 depressed patients with a primary dementia did not differ either on admission or at discharge from the scores of 61 depressed patients without dementia. Controlling for psychiatric diagnosis, cognitive impairment had no significant effect on Ham-D scores. Medical burden accounted for less than 6% of the variance in admission Ham-D yields valid ratings of the severity of depressive symptoms in elderly patients with a broad range of cognitive impairment and physical illness.

The Dementia Signs and Symptoms Scale: A New Scale for Comprehensive Assessment of Psychopathology in Alzheimer's Disease

The Dementia Signs and Symptoms (DSS) Scale documents non-cognitive signs and symptoms (e.g., delusions, hallucinations, anxiety, depression, mania, and behavioral disturbances) in dementia. Patients, informants, and a clinical examiner rated signs and symptoms over the preceding month. Fifty-six Alzheimer's disease patients were administered the DSS, the BEHAVE-AD, the Cornell Scale for Depression in Dementia, the Young Mania Rating Scales, the Hamilton Depression Scale, the Hamilton Anxiety Scale, and the Psychogeriatric Dependency Rating Scale. DSS subscale scores correlated with corresponding scale scores, confirming construct validity. The DSS subscales were internally consistent (Cronbach's alpha, 0.3 7-0.75) and interrater reliability was high (ICC, 0.92-0.99).

A Collateral Source Version of the Geriatric Depression Rating Scale

One hundred ninety-four patients undergoing comprehensive geriatric assessment completed the Geriatric Depression Scale (GDS), and their collateral source (CS) completed a CS version of the GDS (CS-GDS). The results were compared with the blind, prospective diagnoses made by geriatric psychiatrists. The CSs reported the presence of 28 of 30 symptoms significantly more often than the patients. Receiver operating characteristic curve analyses showed good agreement among the clinical diagnoses and both the patient-completed GDS and the CS-completed CS-GDS. At cutoff scores used in prior studies of the GDS, the CS-GDS had limited specificity and poor positive predictive value.

Primary or depressive dementia: mental status screening

In the course of interviewing a patient, several aspects of everyday functioning must be covered to provide a range of observations necessary to suggest a provisional diagnosis. First organized by Adolf Meyer, the mental status examination consists of several techniques which, in recent times, have been shortened, structured and standardized to cover maximal ground in minimal time. In this article, the most popular scales are reviewed psychometrically for their capacity to detect, as first-stage instruments, cognitive impairment suggestive of primary dementia in the context of varying prevalence rates and confounding factors like sensory impairments, sociodemographics and depressive states. Several of the measures are found adequate in some respects though not in others, but all of the better ones, when used as front line implements during clinical intake, regularly improve detection over base rates. An analytical method modelled on ROC procedures is then described contrasting two of them before newer instruments are considered which aim to improve sensitivity at relatively little cost to specificity.

Tailoring adult psychiatric practices to the field of geriatrics

The United States' population is aging. Epidemiological surveys suggest significant rates of mental illness amongst the rapidly growing over-65 cohort. A burgeoning experience and data base related to the developing sub-discipline of geriatric psychiatry is now available. This article synthesizes key issues and concepts as an introduction to geropsychiatric practice-in particular, a) the interface between medical illness and psychiatric expression in the elderly, b) delirium, c) dementia, and d) depression-and considers their interactions. Finally, there is a brief overview of geriatric psychopharmacology, followed by clinically-oriented discussions of each of the major classes of psychotropics as applied to a geriatric population.