Late-life depression with comorbid cognitive impairment and disability: nonpharmacological interventions

The differential effect of emotional loneliness and social loneliness on late-life depression

OBJECTIVES

Loneliness adversely affects the prognosis, treatment, and remission of late-life depression. However, no clear distinction of the cause or definition of loneliness was imposed in existing literatures, resulting in mixed findings of the effect of loneliness to late-life depression (LLD). The aim of this study was to explore the association between different facets of loneliness and risk factors of LLD, specifically, if age of onset in LLD possess a different clinical profile in the clinical group.

METHOD

101 Chinese patients with depression and 81 healthy elderlies aged 60 or above were assessed on loneliness level, depressive symptoms, cognitive symptoms, physical condition, and motivational level. Univariate analyses were applied in exploring group differences in clinical profiles and multivariate regression to determine variables associated with subsets of loneliness.

RESULTS

LLD patients reported more emotional loneliness but not social loneliness than healthy controls (p < 0.001). Emotional loneliness was the only significant predictor of suicidal ideation, particularly on patients with early-onset depression, explaining 26.8% of the effect (p < 0.001). Finally, the effect of medical comorbidity on depression severity was mediated by emotional loneliness(Z = 2.159, p = 0.031).

CONCLUSION

The current research highlights more attention should be placed on the age of onset and medical comorbidity in elderlies with depression. The distinction between emotional loneliness and social loneliness is better understood in the Asian population, reinforcing the importance of taking cultural influence into account when understanding psychological constructs.

Self-reported quality of life in people with dementia attending a day-care programme in Norway: A 24-month quasi-experimental study

The objectives of the study were (a) to compare self-reported Quality of Life (QoL) in a 24-month follow-up of people with dementia attending day care designed for people with dementia (day-care group, DC) with people with dementia who did not attend day care (control group, CG) and (b) to explore factors associated with QoL. A quasi-experimental design with a 24-month follow-up period was used. The DC group included 181 participants recruited from 53 day-care services. The CG included 76 participants recruited from 19 municipalities with no available day care designed for people with dementia. The sample covered the four health regions of Norway and inclusion period lasted from December 2013 to July 2015. The Quality of Life in Alzheimer's Disease (QoL-AD) scale was used as the outcome measure. The differences in QoL between groups and the associations between participant characteristics and QoL, such as depressive symptoms and functional dependency, were examined using a linear mixed model. In the multiple model, the overall trend in QoL did not differ significantly between the DC and CG. However, the DC group exhibited significantly higher self-reported QoL than the CG at all time points (p < 0.001 at T0, p = 0.018 at T12, and p = 0.006 at T24). Participants with shallow or no awareness who attended day care had significantly higher scores on QoL-AD than persons with full awareness (p = 0.017). More depressive symptoms (p < 0.001) and higher functional dependency (p < 0.001) were associated with lower self-reported QoL. The study revealed higher scores of self-reported QoL among people attending day care compared with those who did not attend, showing that day care might have positive impact on the lives of people with dementia.

Changes in depressive symptoms and cognitive impairment in older long-stay nursing home residents in the USA: a latent transition analysis

OBJECTIVES

To longitudinally examine the latent statuses of depressive symptoms and their association with cognitive impairment in older U.S. nursing home (NH) residents.

METHOD

Using Minimum Data Set 3.0, newly-admitted, long-stay, older NH residents with depression in 2014 were identified (n = 88,532). Depressive symptoms (Patient Health Questionnaire-9) and cognitive impairment (Brief Interview of Mental Status) were measured at admission and 90 days. Latent transition analysis was used to examine the prevalence of and the transition between latent statuses of depressive symptoms from admission to 90 days, and the association of cognitive impairment with the statuses at admission.

RESULTS

Four latent statuses of depressive symptoms were identified: 'Multiple Symptoms' (prevalence at admission: 17.3%; 90 days: 13.6%), 'Depressed mood' (20.0%; 19.5%), 'Fatigue' (27.4%; 25.7%), and 'Minimal Symptoms' (35.3%; 41.2%). Most residents remained in the same status from admission to 90 days. Compared to residents who were cognitively intact, those with moderate impairment were more likely to be in 'Multiple Symptoms' and 'Fatigue' statuses; those with severe impairment had lower odds of belonging to 'Multiple Symptoms', 'Depressed Mood', and 'Fatigue' statuses.

CONCLUSION

By addressing the longitudinal changes in the heterogeneous depressive symptoms and the role of cognitive impairment, findings have implications for depression management in older NH residents.

Differences in Trajectories and Predictive Factors of Cognition over Time in a Sample of Cognitively Healthy Adults, in Zaragoza, Spain

Great inter-individual variability has been reported in the maintenance of cognitive function in aging. We examined this heterogeneity by modeling cognitive trajectories in a population-based longitudinal study of adults aged 55+ years. We hypothesized that (1) distinct classes of cognitive trajectories would be found, and (2) between-class differences in associated factors would be observed. The sample comprised 2403 cognitively healthy individuals from the Zaragoza Dementia and Depression (ZARADEMP) project, who had at least three measurements of the Mini-Mental State Examination (MMSE) in a 12-year follow-up. Longitudinal changes in cognitive functioning were modeled using growth mixture models (GMM) in the data. The best-fitting age-adjusted model showed 3 distinct trajectories, with 1-high-to-moderate (21.2% of participants), 2-moderate-stable (67.5%) and, 3-low-and-declining (9.9%) cognitive function over time, respectively. Compared with the reference 2-trajectory, the association of education and depression was significantly different in trajectories 1 and 3. Instrumental activities of daily living (iADLs) were only associated with the declining trajectory. This suggests that intervention strategies should be tailored specifically to individuals with different trajectories of cognitive aging, and intervention strategies designed to maintain cognitive function might be different from those to prevent decline. A stable cognitive performance ('successful cognitive aging') rather than a mild decline, might be more 'normal' than generally expected.

Problem-solving therapy for major depressive disorders in older adults: an updated systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Major depressive disorder is a global public health problem among older adults. Many studies show that problem-solving therapy (PST) is a cognitive behavioral approach that can effectively treat late-life depression.

AIM

To summarize and assess the effects of PST on major depressive disorders in older adults.

METHODS

We searched the PubMed, Web of Science, Cochrane Library, EMBASE, MEDLINE, UpToDate, and PsycINFO databases and three Chinese databases (CNKI, CBM, and Wan Fang Data) to identify articles written in English or Chinese that were published until Feb 1, 2020. Randomized controlled trials were included if they evaluated the impact of PST on major depression disorder (MDD) in older adults. Two authors of this review independently selected the studies, assessed the risk of bias, and extracted the data from all the included studies. We calculated the standard mean differences (SMDs) with 95% confidence intervals (CIs) for continuous data. We assessed heterogeneity using the I² statistic.

RESULTS

Ten studies with a total of 892 participants met the inclusion criteria. Subgroup analyses and quality ratings were performed. After problem-solving therapy, the depression scores in the intervention group were significantly lower than those in the control group (SMD = - 1.06, 95% CI - 1.52 to - 0.61, p < 0.05; I² = 88.4%).

DISCUSSION

Compared with waitlist (WL), PST has a significant effect on elderly patients with depression, but we cannot rank the therapeutic effects of all the treatment methods used for MDD.

CONCLUSIONS

Our meta-analysis and systematic review suggest that problem-solving therapy may be an effective approach to improve major depressive disorders in older adults.

A Narrative Review Examining the Utility of Interpersonal Synchrony for the Caregiver-Care Recipient Relationship in Alzheimer's Disease and Related Dementias

The stressful nature of caring for an older adult with a chronic disease, such as Alzheimer’s disease (AD), can create barriers between the caregiver-care recipient, as they try to navigate their continuously changing social relationship. Interpersonal synchrony (i.e., matching or similarity of movement, emotions, hormones, or brain activity), is an innovative approach that could help to sustain caregiving relationship dynamics by promoting feelings of connection and empathy through shared behavior and experiences. This review investigates the current literature on interpersonal synchrony from an interdisciplinary perspective by examining interpersonal synchrony through psychological, neural, and hormonal measures across the adult lifespan. We then present a case for examining the degree to which interpersonal synchrony can be used to facilitate affiliation and well-being in the caregiver-care recipient relationship. We find that there is significant evidence in healthy adult populations that interpersonal synchrony can support affiliative feelings, prosocial behavior, and well-being. Characterizing the psychological, neural, and hormonal mechanisms of interpersonal synchrony is a first step towards laying the groundwork for the development of tools to support relational closeness and empathy in the caregiving context. Finally, we explore the strengths and limitations of using interpersonal synchrony to support relational well-being, and discuss possible avenues for future research.

Intensity and type of physical activity predicts depression in older adults

This study examined whether various levels of physical activity among older adults predicted levels of depression and whether there were racial differences in the levels and types of physical activities engaged in by adults aged 50 and older.

METHOD

Data from the 2015-2016 National Health and Nutrition Examination Survey (NHANES) were analyzed for 2,474 adults aged 50 years and older. Variables of focus were demographics, physical activity and depression, assessed using the Physical Activity Questionnaire and the Mental Health - Depression Screener.

RESULTS

There was a significant positive relationship between income and depression; individuals with higher income had lower levels of depression. Simple linear regression revealed income significantly predicted depression scores, b = -.20, F(1, 2296) = 96.35, p < .001, explaining 4% of the variance, R2 = .04. As age increased, all levels of physical activity declined, regardless of the category. Vigorous recreation-related activity and moderate recreation-related activity each made significant, unique contributions to depression scores.

CONCLUSION

Findings from the current study suggest that physical activity interventions should be culturally appropriate and tailored to the needs and abilities of individual older adults to maximize benefits and minimize adverse events, particularly among community dwelling older adults.

Predictors of Memory in Healthy Aging: Polyunsaturated Fatty Acid Balance and Fornix White Matter Integrity

Recent evidence demonstrates that age and disease-related decline in cognition depends not only upon degeneration in brain structure and function, but also on dietary intake and nutritional status. Memory, a potential preclinical marker of Alzheimer's disease, is supported by white matter integrity in the brain and dietary patterns high in omega-3 and omega-6 polyunsaturated fatty acids. However, the extent to which memory is supported by specific omega-3 and omega-6 polyunsaturated fatty acids, and the degree to which this relationship is reliant upon microstructure of particular white matter regions is not known. This study therefore examined the cross-sectional relationship between empirically-derived patterns of omega-3 and omega-6 polyunsaturated fatty acids (represented by nutrient biomarker patterns), memory, and regional white matter microstructure in healthy, older adults. We measured thirteen plasma phospholipid omega-3 and omega-6 polyunsaturated fatty acids, memory, and regional white matter microstructure in 94 cognitively intact older adults (65 to 75 years old). A three-step mediation analysis was implemented using multivariate linear regressions, adjusted for age, gender, education, income, depression status, and body mass index. The mediation analysis revealed that a mixture of plasma phospholipid omega-3 and omega-6 polyunsaturated fatty acids is linked to memory and that white matter microstructure of the fornix fully mediates the relationship between this pattern of plasma phospholipid polyunsaturated fatty acids and memory. These results suggest that memory may be optimally supported by a balance of plasma phospholipid omega-3 and omega-6 polyunsaturated fatty acids through the preservation of fornix white matter microstructure in cognitively intact older adults. This report provides novel evidence for the benefits of plasma phospholipid omega-3 and omega-6 polyunsaturated fatty acid balance on memory and underlying white matter microstructure.

Antiglucocorticoid therapy for older adults with anxiety and co-occurring cognitive dysfunction: results from a pilot study with mifepristone

OBJECTIVES

In older adults with anxiety disorders, chronically elevated cortisol may contribute to cognitive impairment and elevated anxiety. We conducted a pilot study with mifepristone, a glucocorticoid receptor antagonist, as a potential treatment for late-life anxiety disorders and co-occurring cognitive dysfunction.

METHODS

Fifteen individuals 60 years and older with an anxiety disorder plus cognitive dysfunction participated in the 12-week study. In the first week, participants were randomly assigned to mifepristone 300 mg daily or placebo. In the subsequent 3 weeks, all participants received mifepristone 300 mg. Mifepristone was then discontinued, and the participants were reassessed 8 weeks later. We examined the following: (1) cognitive changes; (2) worry symptom severity; (3) safety and tolerability; and (4) salivary cortisol before, during, and after mifepristone exposure.

RESULTS

Overall safety, tolerability, and high retention supported the feasibility of this research. Participants with higher baseline cortisol levels (peak cortisol >6.0 ng/ml, n = 5) showed improvements in memory, executive function, and worry severity after 3-4 weeks of mifepristone with persistent memory and worry improvements 8 weeks after mifepristone discontinuation. Individuals with low-to-normal baseline cortisol (n = 8) showed little to no improvement. As expected, cortisol levels rose during mifepristone exposure and returned to pretreatment levels 8 weeks after mifepristone discontinuation. In the first week of treatment, there were no differences between placebo-treated and mifepristone-treated participants.

CONCLUSION

The results of this pilot study warrant further testing of antiglucocorticoid agents in late-life anxiety disorders with co-occurring cognitive dysfunction. Mifepristone is hypothesized to have benefits in patients with evidence of glucocorticoid excess. Directions for further study are discussed.

Socioeconomic stratification and multidimensional health trajectories: evidence of convergence in later old age

OBJECTIVES

This research sought to examine socioeconomic stratification in the joint trajectories of physical, emotional, and cognitive functioning among older Americans and how it differs by age groups.

METHODS

We used data from a nationally representative sample of 9,237 Americans age 65 or older from the Health and Retirement Study, who were observed biennially from 1998 to 2010. Joint trajectories of physical, emotional, and cognitive functioning were characterized using a group-based mixture model. We then applied multinomial logistic regression analysis to evaluate their linkages with socioeconomic status and how the linkages differ by age groups.

RESULTS

We identified four distinct patterns of joint changes in physical, emotional, and cognitive functioning over time. Accounting for 29.3%, 23.5%, 24.5%, and 22.6% of the older Americans, respectively, these trajectory patterns characterized groups of individuals experiencing minimal to severe levels of impairment and deterioration. Lower education, income, and net worth were associated with trajectories featuring greater impairment or more rapid deterioration in these functional dimensions. Disparities based on education, however, attenuated in later old age, whereas health benefits associated with higher income and higher net worth persisted into advanced age.

DISCUSSION

Distinct patterns of joint trajectories of physical, emotional, and cognitive functioning exist in old age. There were significant socioeconomic differences in the joint trajectories, with education-based inequality in health converging in later old age. Further research identifying strategies to alleviate the disproportionate burden of poor multidimensional health trajectories in lower socioeconomic groups is important.

Is a change in functional capacity or dependency in activities of daily living associated with a change in mental health among older people living in residential care facilities?

AIM

Functional capacity and dependency in activities of daily living (ADL) could be important mediators for an association between physical exercise and mental health. The aim of this study was to investigate whether a change in functional capacity or dependency in ADL is associated with a change in depressive symptoms and psychological well-being among older people living in residential care facilities, and whether dementia can be a moderating factor for this association.

METHODS

A prospective cohort study was undertaken. Participants were 206 older people, dependent in ADL, living in residential care facilities, 115 (56%) of whom had diagnosed dementia. Multivariate linear regression, with comprehensive adjustment for potential confounders, was used to investigate associations between differences over 3 months in Berg Balance Scale (BBS) and Geriatric Depression Scale (GDS-15) scores, and in BBS and Philadelphia Geriatric Center Morale Scale (PGCMS) scores. Associations were also investigated between differences in Barthel ADL Index and GDS-15 scores, and in Barthel ADL Index and PGCMS scores.

RESULTS

There were no significant associations between changes in scores over 3 months; the unstandardized β for associations between BBS and GDS-15 was 0.026 (P=0.31), BBS and PGCMS 0.045 (P=0.14), Barthel ADL Index and GDS-15 0.123 (P=0.06), and Barthel ADL Index and PGCMS -0.013 (P=0.86). There were no interaction effects for dementia.

CONCLUSION

A change in functional capacity or dependency in ADL does not appear to be associated with a change in depressive symptoms or psychological well-being among older people living in residential care facilities. These results may offer one possible explanation as to why studies of physical exercise to influence these aspects of mental health have not shown effects in this group of older people.

Depression in the elderly: clinical features and risk factors

Depression in elderlies is not known quite well and thus cannot be treated adequately. The fact that elderliness is accepted as a property of depressive symptoms both by the relatives of the patients and doctors is one of the factors which make it difficult to recognize depression. Existence of multiple physical diseases in elderlies, use of multiple medicines, occurrence of pharmacokinetic and pharmacodynamics changes depending on the age necessitate to take several factors into account while diagnosing and using medicines. In this study, clinical properties and risk factors of depression in old age period was reviewed and the properties of such depressions were summarized.

Association of attentional shift and reversal learning to functional deficits in geriatric depression

OBJECTIVE

The objective of this study is to examine the association between self-reported functional disability in depressed older adults and two types of executive function processes, attentional set shifting and reversal learning.

METHODS

Participants (N = 89) were aged 60 or over and enrolled in a naturalistic treatment study of major depressive disorder. Participants provided information on self-reported function in instrumental activities of daily living (IADL) and completed the Intra-Extra Dimensional Set Shift test (IED) from the Cambridge Neuropsychological Testing Automated Battery, which assesses intra-dimensional attentional shifts, extra-dimensional attentional shifts, and reversal learning. Participants were categorized by the presence or absence of IADL difficulties and compared on IED performance using bivariable and multivariable tests.

RESULTS

Participants who reported IADL difficulties had more errors in extra-dimensional attentional shifting and reversal learning, but intra-dimensional shift errors were not associated with IADLs. Only extra-dimensional shift errors were significant in multivariable models that controlled for age, sex, and depression severity.

CONCLUSIONS

Attentional shifting across categories (i.e., extra-dimensional) was most strongly associated with increased IADL difficulties among depressed older adults, which make interventions to improve flexible problem solving a potential target for reducing instrumental disability in this population.

A lifespan view of anxiety disorders

Neurodevelopmental changes over the lifespan, from childhood through adulthood into old age, have important implications for the onset, presentation, course, and treatment of anxiety disorders. This article presents data on anxiety disorders as they appear in older adults, as compared with earlier in life. In this article, we focus on aging-related changes in the epidemiology, presentation, and treatment of anxiety disorders. Also, this article describes some of the gaps and limitations in our understanding and suggests research directions that may elucidate the mechanisms of anxiety disorder development later in life. Finally we describe optimal management of anxiety disorders across the lifespan, in "eight simple steps" for practitioners.