Late- versus early-onset geriatric depression in a memory research center

Regional gray matter volume correlates with anxiety, apathy, and resilience in geriatric depression

OBJECTIVES

Geriatric depression (GD) is associated with significant medical comorbidity, cognitive impairment, brain atrophy, premature mortality, and suboptimal treatment response. While apathy and anxiety are common comorbidities, resilience is a protective factor. Understanding the relationships between brain morphometry, depression, and resilience in GD could inform clinical treatment. Only few studies have addressed gray matter volume (GMV) associations with mood and resilience.

PARTICIPANTS

Forty-nine adults aged >60 years (38 women) with major depressive disorder undergoing concurrent antidepressant treatment participated in the study.

MEASUREMENTS

Anatomical T1-weighted scans, apathy, anxiety, and resilience data were collected. Freesurfer 6.0 was used to preprocess T1-weighted images and qdec to perform voxel-wise whole-brain analyses. Partial Spearman correlations controlling for age and sex tested the associations between clinical scores, and general linear models identified clusters of associations between GMV and clinical scores, with age and sex as covariates. Cluster correction and Monte-Carlo simulations were applied (corrected alpha = 0.05).

RESULTS

Greater depression severity was associated with greater anxiety (r = 0.53, p = 0.0001), lower resilience (r = -0.33, p = 0.03), and greater apathy (r = 0.39, p = 0.01). Greater GMV in widespread, partially overlapping clusters across the brain was associated with reduced anxiety and apathy, as well as increased resilience.

CONCLUSION

Our results suggest that greater GMV in extended brain regions is a potential marker for resilience in GD, while GMV in more focal and overlapping regions may be markers for depression and anxiety. Interventions focused on improving symptoms in GD may seek to examine their effects on these brain regions.

Brain-cognition relationships in late-life depression: a systematic review of structural magnetic resonance imaging studies

BACKGROUND

Most patients with late-life depression (LLD) have cognitive impairment, and at least one-third meet diagnostic criteria for mild cognitive impairment (MCI), a prodrome to Alzheimer's dementia (AD) and other neurodegenerative diseases. However, the mechanisms linking LLD and MCI, and brain alterations underlying impaired cognition in LLD and LLD + MCI remain poorly understood.

METHODS

To address this knowledge gap, we conducted a systematic review of studies of brain-cognition relationships in LLD or LLD + MCI to identify circuits underlying impaired cognition in LLD or LLD + MCI. We searched MEDLINE, PsycINFO, EMBASE, and Web of Science databases from inception through February 13, 2023. We included studies that assessed cognition in patients with LLD or LLD + MCI and acquired: (1) T1-weighted imaging (T1) measuring gray matter volumes or thickness; or (2) diffusion-weighted imaging (DWI) assessing white matter integrity. Due to the heterogeneity in studies, we only conducted a descriptive synthesis.

RESULTS

Our search identified 51 articles, resulting in 33 T1 studies, 17 DWI studies, and 1 study analyzing both T1 and DWI. Despite limitations, reviewed studies suggest that lower thickness or volume in the frontal and temporal regions and widespread lower white matter integrity are associated with impaired cognition in LLD. Lower white matter integrity in the posterior cingulate region (precuneus and corpus callosum sub-regions) was more associated with impairment executive function and processing speed than with memory.

CONCLUSION

Future studies should analyze larger samples of participants with various degrees of cognitive impairment and go beyond univariate statistical models to assess reliable brain-cognition relationships in LLD.

The role of semantic assessment in the differential diagnosis between late-life depression and Alzheimer's disease or amnestic mild cognitive impairment: systematic review and meta-analysis

OBJECT

The cognitive complaints encountered in late-life depression (LLD) make it difficult to distinguish from amnestic mild cognitive impairment (aMCI) and Alzheimer's disease (AD) based on an analysis of neurocognitive disorders. The hypothesis of the early impairment of semantic memory in AD and aMCI is considered a potential differential cognitive clue, but the absence of this impairment has not yet been confirmed in  LLD.

METHOD

Based on the PRISMA method, we systematically seek neuropsychological assessments of individuals with LLD, the present study included 31 studies representing 3291 controls and 2820 people with LLD. Wherever possible, studies that tested simultaneously groups with LLD, AD (or aMCI) were also included. The results of the group of neuropsychological tasks relying on semantic memory were analyzed in two groups of tasks with high- or low-executive demand. The mean average effect of LLD was calculated and compared to the incremental effect of aMCI or AD on the scores. Linear regressions including education, age, and severity and type of depression were run to seek their power of prediction for the mean average effects.

RESULTS

LLD has a medium effect on scores at semantic and phonemic fluency and naming and a small average effect on the low-executive demand tasks. Differences in education is a predictor of the effect of LLD on phonemic fluency and naming but not on semantic fluency or on low-executive demand tasks. Except for semantic fluency, aMCI did not demonstrate an incremental effect on the scores compared to LLD, while AD did, for all the tasks except phonemic fluency.

CONCLUSION

Assessment of semantic memory can be a discriminating clue for the distinction between depression and Alzheimer's disease but some methodological variables are highly influential to the scores, especially education. However, high-executive semantic tasks alone do not allow us to clearly distinguish LLD from AD or aMCI, as both pathologies seem to have a largely dialectical influential relationship, but low-executive semantic tasks appear as more sensible to this pathological distinction.

Biological factors influencing depression in later life: role of aging processes and treatment implications

Late-life depression occurring in older adults is common, recurrent, and malignant. It is characterized by affective symptoms, but also cognitive decline, medical comorbidity, and physical disability. This behavioral and cognitive presentation results from altered function of discrete functional brain networks and circuits. A wide range of factors across the lifespan contributes to fragility and vulnerability of those networks to dysfunction. In many cases, these factors occur earlier in life and contribute to adolescent or earlier adulthood depressive episodes, where the onset was related to adverse childhood events, maladaptive personality traits, reproductive events, or other factors. Other individuals exhibit a later-life onset characterized by medical comorbidity, pro-inflammatory processes, cerebrovascular disease, or developing neurodegenerative processes. These later-life processes may not only lead to vulnerability to the affective symptoms, but also contribute to the comorbid cognitive and physical symptoms. Importantly, repeated depressive episodes themselves may accelerate the aging process by shifting allostatic processes to dysfunctional states and increasing allostatic load through the hypothalamic-pituitary-adrenal axis and inflammatory processes. Over time, this may accelerate the path of biological aging, leading to greater brain atrophy, cognitive decline, and the development of physical decline and frailty. It is unclear whether successful treatment of depression and avoidance of recurrent episodes would shift biological aging processes back towards a more normative trajectory. However, current antidepressant treatments exhibit good efficacy for older adults, including pharmacotherapy, neuromodulation, and psychotherapy, with recent work in these areas providing new guidance on optimal treatment approaches. Moreover, there is a host of nonpharmacological treatment approaches being examined that take advantage of resiliency factors and decrease vulnerability to depression. Thus, while late-life depression is a recurrent yet highly heterogeneous disorder, better phenotypic characterization provides opportunities to better utilize a range of nonspecific and targeted interventions that can promote recovery, resilience, and maintenance of remission.

Towards Defining the Neuroanatomical Basis of Late-Onset Psychiatric Symptoms

Psychiatric symptoms, including changes in emotional processing, are a common feature of many neurodegenerative disorders, such as Alzheimer's disease, dementia with Lewy Bodies, frontotemporal dementia, and Huntington's disease. However, the neuroanatomical basis of emotional symptoms is not well defined; this stands in contrast to the relatively well-understood neuroanatomical correlates of cognitive and motor symptoms in neurodegenerative disorders. Furthermore, psychiatric diagnostic categories, as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Statistical Classification of Diseases and Related Health Problems (ICD), may have limited applicability in patients with late-onset psychiatric symptoms in the context of neurodegenerative disorders. In this clinical review, we suggest that early-onset and late-onset psychiatric symptoms have distinct etiologies, and that late-onset changes in emotional processing are likely underpinned by neurodegenerative disease. Furthermore, we suggest that an improved understanding of the neuroanatomical correlates of emotional changes in neurodegenerative disease may facilitate diagnosis and future treatment development. Finally, we propose a novel clinical approach, in a preliminary attempt to incorporate late-onset emotional symptoms alongside cognitive and motor symptoms into a clinical "algorithm," with a focus on the neuroanatomy implicated when particular combinations of emotional, cognitive, and motor features are present. We anticipate that this clinical approach will assist with the diagnosis of neurodegenerative disorders, and our proposed schema represents a move towards integrating neurologic and psychiatric classification systems.

Effects of combined cognitive and physical intervention on enhancing cognition in older adults with and without mild cognitive impairment: A systematic review and meta-analysis

Background

Combined cognitive and physical intervention is commonly used as a non-pharmacological therapy to improve cognitive function in older adults, but it is uncertain whether combined intervention can produce stronger cognitive gains than either single cognitive or sham intervention. To address this uncertainty, we performed a systematic review and meta-analysis to evaluate the effects of combined intervention on cognition in older adults with and without mild cognitive impairment (MCI).

Methods

We systematically searched eight databases for relevant articles published from inception to November 1, 2021. Randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) were used to compare the effects of the combined intervention with a single cognitive or sham intervention on cognition in older adults with and without MCI aged ≥ 50 years. We also searched Google Scholar, references of the included articles, and relevant reviews. Two independent reviewers performed the article screening, data extraction, and bias assessment. GRADEpro was used to rate the strength of evidence, and RevMan software was used to perform the meta-analysis.

Results

Seventeen studies were included in the analysis, comprising eight studies of cognitively healthy older adults and nine studies of older adults with MCI. The meta-analysis showed that the combined intervention significantly improved most cognitive functions and depression (SMD = 0.99, 95% CI 0.54–1.43, p < 0.0001) in older adults compared to the control groups, but the intervention effects varied by cognition domains. However, there was no statistically significant difference in the maintenance between the combined and sham interventions (SMD = 1.34, 95% CI −0.58–3.27, p = 0.17). The subgroup analysis also showed that there was no statistical difference in the combined intervention to improve global cognition, memory, attention, and executive function between cognitive healthy older adults and older adults with MCI.

Conclusions

Combined intervention improves cognitive functions in older adults with and without MCI, especially in global cognition, memory, and executive function. However, there was no statistical difference in the efficacy of the combined intervention to improve cognition between cognitive healthy older adults and older adults with MCI. Moreover, the maintenance of the combined intervention remains unclear due to the limited follow-up data and high heterogeneity. In the future, more stringent study designs with more follow-ups are needed further to explore the effects of combined intervention in older adults.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier: CRD42021292490.

Differences in Odor Identification in Early-Onset and Late-Onset Depression

(1) Background: Odor identification (OI) dysfunction is a potential predictor of developing dementia in late life depression (LLD). However, it is not clear whether patients with early onset depression (EOD) and late onset depression (LOD) may exhibit different OI dysfunctions. The aim of this study was to compare OI between EOD patients and LOD patients and its relationship with cognitive function. (2) Methods: A total of 179 patients with LLD and 189 normal controls were recruited. Participants underwent clinical assessment, olfactory testing, and comprehensive neuropsychological assessment. The OI scores of EOD patients and LOD patients were compared, and correlation analyses and mediation analyses were used to explore the relationship between OI and cognition. (3) Result: LOD patients exhibited lower OI scores than EOD patients and normal controls (NCs). Additionally, the LOD patients exhibited a higher percentage of OI dysfunction than the EOD patients. Moreover, OI scores were associated with global cognition, memory, language, and visuospatial ability in the EOD group (p < 0.05) but were not associated with any cognitive score in the LOD patients (p > 0.05). Finally, the scores of the Auditory Verbal Learning Test Immediate recall and Boston Naming Test exhibited a partially mediating effect on the difference in OI scores between the EOD and LOD patients. (4) Conclusions: LOD patients exhibited worse OI than EOD patients, and their difference in OI was mediated by their memory and language function.

Heterogenous Subtypes of Late-Life Depression and Their Cognitive Patterns: A Latent Class Analysis

BACKGROUND

Late-life depression (LLD), characterized by cognitive deficits, is considered heterogeneous across individuals. Previous studies have identified subtypes with diverse symptom profiles, but their cognitive patterns are unknown. This study aimed to investigate the subtypes of LLD and the cognitive profile of each group.

METHODS

In total, 109 depressed older adults were enrolled. We performed latent class analysis using Geriatric Depression Scale items as indicators to generate latent classes. We compared the sociodemographic and clinical characteristics with cognitive functions between groups and conducted regression analysis to investigate the association between class membership and variables with significant differences.

RESULTS

Two classes were identified: the "pessimistic" group was characterized by pessimistic thoughts and the "worried" group with a relatively high prevalence of worry symptoms. The two groups did not differ in sociodemographic characteristics. The "pessimistic" group showed a higher rate of past history of depression and lower age of onset. The "worried" group had more physical comorbidities and a higher rate of past history of anxiety. The "pessimistic" group was more impaired in general cognitive function, executive function, information processing speed, and attention. Lower general and executive functions were associated with the membership in the "pessimistic" group.

CONCLUSIONS

Subjects with pessimistic symptoms and subjects with a propensity to worry may form two distinct subtypes of late-life depression with different cognitive profiles. Further, the cognitive evaluation of subjects with pessimistic symptoms is of utmost importance.

Different Modular Organization Between Early Onset and Late Onset Depression: A Study Base on Granger Causality Analysis

Background: Modular organization reflects the activity patterns of our brain. Different disease states may lead to different activity patterns and clinical features. Early onset depression (EOD) and late onset depression (LOD) share the same clinical symptoms, but have different treatment strategies and prognosis. Thus, explored the modular organization of EOD and LOD might help us understand their pathogenesis.

Method: The study included 82 patients with late life depression (EOD 40, LOD 42) and 90 healthy controls. We evaluated the memory, executive function and processing speed and performed resting-stage functional MRI for all participants. We constructed a functional network based on Granger causality analysis and carried out modularity, normalized mutual information (NMI), Phi coefficient, within module degree z-score, and participation coefficient analyses for all the participants.

Result: The Granger function network analysis suggested that the functional modularity was different among the three groups (P_auc = 0.0300), and NMI analysis confirmed that the partition of EOD was different from that of LOD (P_auc = 0.0190). Rh.10d.ROI (polar frontal cortex) and Rh.IPS1.ROI (dorsal stream visual cortex) were shown to be the potential specific nodes in the modular assignment according to the Phi coefficient (P = 0.0002, P_fdr = 0.0744 & P = 0.0004, P_fdr = 0.0744).

Conclusion: This study reveal that the functional modularity and partition were different between EOD and LOD in Granger function network. These findings support the hypothesis that different pathological changes might exist in EOD and LOD.

Comparison of cognitive function between early- and late-onset late-life depression in remission

Differences in cognitive function have been suggested in people with late-life depression between those with early- (EOD) and late-onset (LOD), possibly reflecting different etiologies. The cutoff point for EOD and LOD was the first depressive episode before age 60 or later. However, depressive symptoms at the time of disorder are important confounders. The study aimed to compare cognitive function in older people with EOD and LOD in the euthymic state. A sample of 135 participants aged 60+ with a history of major depressive disorder in remission, received neuropsychological evaluation including tests of memory, attention, processing speed, visuospatial function, language, and executive function. Individual test scores and a derived composite score were investigated as dependent variables against age of onset using multiple linear regressions adjusted for potential confounders, including residual depressive symptoms. We found EOD (N = 67) and LOD (N = 68) groups did not differ significantly in overall composite cognitive scores after adjustment. Of individual test scores, only those for immediate recall were significantly lower in participants with EOD compared to LOD. In conclusion, the study found no associations between cognitive function and age of onset in this sample of people with depressive disorder in remission. Active or residual depressive symptoms might have confounded this relationship in previous research.

Electroconvulsive therapy response in late-life depression unaffected by age-related brain changes

BACKGROUND

Gray matter volume decrease, white matter vascular pathology and amyloid accumulation are age-related brain changes that have been related to the pathogenesis of late life depression (LLD). Furthermore, lower hippocampal volume and more white matter hyperintensities (WMH) may contribute to poor response to electroconvulsive therapy (ECT) in severely depressed older adults. We hypothesized that the accumulation of age-related brain changes negatively affects outcome following ECT in LLD.

METHODS

34 elderly patients with severe LLD were treated twice weekly with ECT until remission. All had both 3T structural magnetic resonance imaging (MRI) and β-amyloid positron emission tomography (PET) imaging using 18F-flutemetamol at baseline. MADRS and MMSE were obtained weekly which included 1 week prior to ECT (T0), after the sixth ECT (T1), and one week (T2) after the last ECT as well as at four weeks (T3) and 6 months (T4) after the last ECT. We conducted a multiple logistic regression analysis and a survival analysis with neuroimaging measures as predictors, and response, remission and relapse as outcome variable.

RESULTS

We did not find any association between baseline hippocampal volume, white matter hyperintensity volume and total amyloid load and response or remission at 1 and 4 weeks post ECT, nor with relapse at week 4.

LIMITATIONS

The present exploratory study was conducted at a single center academic hospital, the sample size was small, the focus was on hippocampal volume and the predictive effect of structural and molecular changes associated with aging were used.

CONCLUSIONS

Our study shows no evidence of relationship between response to ECT and age-related structural or molecular brain changes, implying that ECT can be applied effectively in depressed patients irrespective of accumulating age-related brain changes.

Psychobiological factors of resilience and depression in late life

In contrast to traditional perspectives of resilience as a stable, trait-like characteristic, resilience is now recognized as a multidimentional, dynamic capacity influenced by life-long interactions between internal and environmental resources. We review psychosocial and neurobiological factors associated with resilience to late-life depression (LLD). Recent research has identified both psychosocial characteristics associated with elevated LLD risk (e.g., insecure attachment, neuroticism) and psychosocial processes that may be useful intervention targets (e.g., self-efficacy, sense of purpose, coping behaviors, social support). Psychobiological factors include a variety of endocrine, genetic, inflammatory, metabolic, neural, and cardiovascular processes that bidirectionally interact to affect risk for LLD onset and course of illness. Several resilience-enhancing intervention modalities show promise for the prevention and treatment of LLD, including cognitive/psychological or mind-body (positive psychology; psychotherapy; heart rate variability biofeedback; meditation), movement-based (aerobic exercise; yoga; tai chi), and biological approaches (pharmacotherapy, electroconvulsive therapy). Additional research is needed to further elucidate psychosocial and biological factors that affect risk and course of LLD. In addition, research to identify psychobiological factors predicting differential treatment response to various interventions will be essential to the development of more individualized and effective approaches to the prevention and treatment of LLD.

Investigating the relationship between age of onset of depressive disorder and cognitive function

OBJECTIVES

Depressive disorder is commonly associated with impaired cognitive function; however, it is unclear whether the age of onset of the first episode of depression, current depression severity, or historical severity of depressive episodes are associated with cognitive performance.

METHODS

This study examined baseline cross-sectional data from the ongoing online PROTECT study. A total of 7344 participants, 50 years or older, with a history of depression and no diagnosis of dementia were divided into three groups according to age of onset of their first depressive episode: early-onset, midlife-onset, and late-onset. Performance on measures of visuospatial episodic memory, executive function, verbal working, and visual working memory were evaluated. Demographic and clinical characteristics such as age, education, and severity of symptoms during their worst previous depressive episode and current depression severity were included in multivariate regression models.

RESULTS

The late-onset depression group scored significantly lower on the verbal reasoning task than the early-onset group while there were no significant differences found on the other tasks. Midlife-onset depression participants performed better in the visual episodic memory task, but worse on the verbal reasoning task, than early-onset depression participants. Current depression severity was negatively correlated with all four cognitive domains, while historical severity score was found to be significantly associated with cognitive performance on the verbal reasoning and spatial working memory tasks.

CONCLUSIONS

The most important indicator of cognitive performance in depression appears to be current, rather than historic depression severity; however, late-onset depression may be associated with more executive impairment than an early-onset depression.

Electroconvulsive therapy for older adult patients with major depressive disorder: a systematic review of randomized controlled trials

BACKGROUND

Electroconvulsive therapy (ECT) has been widely used in treating older adult patients with major depressive disorder. The results of randomized controlled trials (RCT) are mixed. This study systematically examined the efficacy and safety of ECT versus antidepressants (AD) in older adult patients with major depressive disorder.

METHODS

A literature search was conducted independently by two reviewers using the PubMed, Embase, PsycINFO, Cochrane Library, Chinese National Knowledge Infrastructure, Wanfang, and SinoMed databases from their inceptions until 17 May 2017. The Cochrane risk of bias and Jadad scale were used to assess the quality of RCT included in the systematic review.

RESULTS

Five RCT (n = 374; mean age: 66.0-66.4 years; men: 36.4-58.3%) all conducted in China were identified, including three RCT (n = 203) with ECT alone and two RCT (n = 171) with ECT-AD co-treatment. In two of the three RCT, ECT alone was superior to AD monotherapy in improving depressive symptoms as assessed by the Hamilton Depression Scale and by clinical judgement at the conclusion of the course of ECT. Both RCT of AD-ECT co-treatment showed a significant reduction in the Hamilton Depression Scale total score after ECT compared with AD monotherapy. The response rate ranged from 80% to 97.5% in the ECT groups and from 63.4% to 73.3% in the AD groups. Rates of adverse reactions were similar between ECT and AD groups in studies with available data. Only one RCT reported the discontinuation rate without a significant group difference.

CONCLUSIONS

This systematic review showed that ECT appears to be an effective and safe treatment for older adult patients with major depressive disorder. Further high-quality studies with extended follow-up are warranted.

Depressive symptoms and cognitive functioning among older adults with cancer. Aging Ment Health 2018;22:1465-1470. [PMID: 28786290 DOI: 10.1080/13607863.2017.1363868]

OBJECTIVE

The US population of older adults is growing, with an increase in diseases like cancer. As cancer rates increase, there is a concomitant increase in adverse correlates, such as cognitive impairment and depressive symptomatology. In order to develop appropriate interventions, it is vital to assess relationships among cancer, depressive symptoms and cognitive functioning.

METHODS

The sample consisted of 403 older adults with cancer diagnoses from the Health and Retirement Study. Using latent class growth analysis, longitudinal data were explored. The goals were to investigate trajectories of cognitive functioning, and to identify whether depressive symptoms and demographic factors predicted membership in the cognitive classes.

RESULTS

Three classes of cognitive functioning best fit the data: High, Middle and Low Recall, fairly stable trajectories from pre-diagnosis to a period four years after diagnosis. More depressive symptoms after diagnosis (but not prior) significantly predicted membership in the Low Recall class. Depressive symptoms did not distinguish between the High and Middle Recall classes.

CONCLUSION

Depressive symptomatology is thought to affect cognition in late life. We found that depressive symptoms after a cancer diagnosis, but not before, successfully differentiated between those who had Low Recall from those with Middle and High Recall. Implications are discussed.

Depression and Risk of Alzheimer Dementia: A Longitudinal Analysis to Determine Predictors of Increased Risk among Older Adults with Depression

OBJECTIVE

Older adults with depression are at increased risk of Alzheimer dementia, but predictors of increased risk remain incompletely understood. We aim to identify characteristics of older adults with depression most at risk of progressing to Alzheimer dementia. Identification of high-risk subgroups could facilitate future interventional strategies to reduce risk of Alzheimer dementia in older adults with depression.

METHODS

Using data from the National Alzheimer's Coordinating Center, 1,965 participants with clinically defined depression and mild cognitive impairment at baseline were followed until development of Alzheimer dementia or loss to follow-up.

RESULTS

Seven hundred and eighty (39.7%) developed Alzheimer dementia over a median follow-up duration of 27 months. In survival analyses, age (hazard ratio [HR] 1.04, 95% 1.03-1.05), baseline Mini-Mental State Exam (HR 0.85, 95% confidence interval 0.83-0.87), amnestic subtype of mild cognitive impairment (HR 1.66, 95% 1.30-2.12), presence of APOE4 allele (HR 1.99, 1.69-2.36), and presence of active depression within the last two years (HR 1.44, 95% confidence interval 1.16-1.79) were all independently associated with increased risk of Alzheimer dementia. Six hundred and fifty-six (41.7%) participants with mild cognitive impairment and active depression within the last two years developed Alzheimer dementia compared to 120 (31.6%) of those with a more remote history of depression.

CONCLUSION

Older adults with depression and mild cognitive impairment demonstrated a high rate of progression to Alzheimer dementia over a relatively short duration of follow-up. Individuals with a combination of mild cognitive impairment and recently active depression are a particularly high-risk subgroup.

Neuropsychological deficits in elderly with depression

BACKGROUND

Depressed patients are preoccupied with unhappy thoughts which reduce their capacity to focus on attention, memory, and other cognitive performance.

AIM

The aim of this study is to assess neuropsychological deficits in elderly depressive and compare it with matched normal controls.

METHODS

After consideration of inclusion and exclusion criteria, the sample of 30 elderly depressive patients diagnosed on the basis of International Classification of Diseases, Tenth Edition criteria and 30 normal controls were selected. The selection of sample was by purposive sampling from private psychiatric clinic of Bhopal. The age range of sample was 60 years and above. All participants were administered the Geriatric Depression Scale, and the Luria-Nebraska Neuropsychological Battery-1 (LNNB form-1).

RESULTS

On the Geriatric Depression Scale, 21 patients were at mild level and nine patients were at severe level of depression. None of the normal controls were depressed. On LNNB form-1, depressive patients showed significant elevation on receptive speech, arithmetic, memory, reading, writing, and expressive speech as compared to normal controls.

CONCLUSION

Older depressive patients showed significantly more neurocognitive deficits as compared to normal controls. It is important that these deficits are identified and addressed for the holistic treatment of late-onset depression.

Early- and Late-Onset Depression in Late Life: A Prospective Study on Clinical and Structural Brain Characteristics and Response to Electroconvulsive Therapy

OBJECTIVE

The clinical profile of late-life depression (LLD) is frequently associated with cognitive impairment, aging-related brain changes, and somatic comorbidity. This two-site naturalistic longitudinal study aimed to explore differences in clinical and brain characteristics and response to electroconvulsive therapy (ECT) in early- (EOD) versus late-onset (LOD) late-life depression (respectively onset <55 and ≥55 years).

METHODS

Between January 2011 and December 2013, 110 patients aged 55 years and older with ECT-treated unipolar depression were included in The Mood Disorders in Elderly treated with ECT study. Clinical profile and somatic health were assessed. Magnetic resonance imaging (MRI) scans were performed before the first ECT and visually rated.

RESULTS

Response rate was 78.2% and similar between the two sites but significantly higher in LOD compared with EOD (86.9 versus 67.3%). Clinical, somatic, and brain characteristics were not different between EOD and LOD. Response to ECT was associated with late age at onset and presence of psychotic symptoms and not with structural MRI characteristics. In EOD only, the odds for a higher response were associated with a shorter index episode.

CONCLUSION

The clinical profile, somatic comorbidities, and brain characteristics in LLD were similar in EOD and LOD. Nevertheless, patients with LOD showed a superior response to ECT compared with patients with EOD. Our results indicate that ECT is very effective in LLD, even in vascular burdened patients.

Neuromodulation therapies for geriatric depression

Depression is frequent in old age and its prognosis is poorer than in younger populations. The use of pharmacological treatments in geriatric depression is limited by specific pharmacodynamic age-related factors that can diminish tolerability and increase the risk of drug interactions. The possibility of modulating cerebral activity using brain stimulation techniques could result in treating geriatric depression more effectively while reducing systemic side effects and medication interactions. This may subsequently improve treatment adherence and overall prognosis in the older patient. Among clinically available neuromodulatory techniques, electroconvulsive therapy (ECT) remains the gold standard for the treatment of severe depression in the elderly. Studies have proven that ECT is more effective and has a faster onset of action than antidepressants in the treatment of severe, unipolar, geriatric depression and that older age is a predictor of rapid ECT response and remission. The application of novel and more tolerable forms of ECT for geriatric depression is currently being examined. Preliminary results suggest that right unilateral ultrabrief ECT (RUL-UB ECT) is a promising intervention, with similar efficacy to brief-pulse ECT and fewer adverse cognitive effects. Overall findings in repetitive transcranial magnetic stimulation (rTMS) suggest that it is a safe intervention in geriatric depression. Higher rTMS stimulation intensity and more treatments may need to be given in the elderly to achieve optimal results. There is no specific data on vagus nerve stimulation in the elderly. Transcranial direct current stimulation, magnetic seizure therapy and deep brain stimulation are currently experimental, and more data from geriatric samples is needed.

The new DSM-5 diagnosis of mild neurocognitive disorder and its relation to research in mild cognitive impairment

The Diagnostic Statistical Manual-5 (DSM-5) has included a category named the neurocognitive disorder which was formally known in DSM-IV as 'dementia, delirium, amnestic, and other cognitive disorders'. The DSM-5 distinguishes between 'mild' and 'major' neurocognitive disorders. Major neurocognitive disorder replaces the DSM-IV's term 'dementia or other debilitating conditions'. A pivotal addition is 'mild neurocognitive disorder (mNCD)' defined by a noticeable decrement in cognitive functioning that goes beyond normal changes seen in aging. It is a disorder that may progress to dementia - importantly, it may not. Presently, our understanding of mNCD is derived from research on mild cognitive impairment (MCI). Whereas there is currently no clear treatment for mNCD, many experimental therapies now and into the future will focus upon secondary prevention, namely decreasing the risk of progression to major NCD. In this article, we will focus on mNCD by reviewing the relevant literature on MCI. We will review the research on the incidence and prevalence of MCI, conversion rates from MCI to dementia, risk factors for conversion of MCI to dementia, comorbidity of MCI with other neuropsychiatric disorders (NPS), and the development of treatment strategies for neuropsychiatric disorders in MCI. The presence of NPS is common among individuals with MCI and is an important risk for progression to dementia. However, there has been little research on effective treatments for NPS in MCI. Clinicians and investigators must determine if the treatment of the NPS in mNCD will improve quality of life and help reduce the progression of the cognitive impairment.

Association of age at depression onset with cognitive functioning in individuals with late-life depression and executive dysfunction

OBJECTIVE

To compare patterns of cognitive performance in older adults with late-onset depression (LOD; ≥65 years of age) with that of older adults with early-onset depression (EOD; <65 years).

METHODS

Participants were 171 adults aged 60 years or older with major depression and executive dysfunction who were participating in a randomized psychotherapy trial. Participants included 72 LOD and 99 EOD individuals. Cognitive performance on measures of verbal learning, memory, and executive functioning were evaluated. Demographic and clinical characteristics, severity of cerebrovascular risk factors, and disability ratings were also compared between groups.

RESULTS

The LOD group was older and had fewer previous episodes of depression and lower severity of depression compared with EOD participants. The LOD group demonstrated poorer performance on measures of verbal learning (F(1,161) = 4.28, p = 0.04) and memory (F(1,160) = 4.65, p = 0.03) than the EOD group. Linear regression analysis demonstrated that LOD and fewer years of education were significant predictors of poorer verbal learning (F(7,114) = 6.25, p <0.001) and memory (F(7,113)=7.24, p <0.001). Performance on measures of executive functioning, severity of vascular risk factors, and disability ratings did not differ between the two groups.

CONCLUSION

In older adults with depression and executive dysfunction, LOD was associated with poorer performance on measures of verbal learning and memory. Aging-related brain changes associated with LOD may play a more important role, leading to dysfunction in these cognitive domains than a history of recurrent depressive episodes in older adults with a dysexecutive syndrome.

Melancholia in later life: late and early onset differences in presentation, course, and dementia risk

OBJECTIVES

Depression is a risk factor for cognitive decline and dementia. This risk may vary with age of onset and depression subtype. Late onset depression (LOD, 60 years and older) is associated with more cognitive decline, whereas early onset depression (EOD, before 60 years) is associated with more residual depressive symptoms. Potential differences may reflect divergent etiologies. These onset differences, however, have not been examined in the melancholic subtype of depression in older adults.

METHODS

Data were obtained from the Neurocognitive Outcomes of Depression in the Elderly study. Participants (N = 284, 73% EOD-melancholic (EOD-M) and 27% LOD-melancholic (LOD-M)) were followed up over 3 years. Factor analyses examined differences in baseline depressive symptoms. Hierarchical linear growth curve models examined changes in depressive symptoms (Montgomery-Asberg Depression Rating Scale) and cognition (mini mental state examination). An annual clinical review panel assigned diagnoses of dementia.

RESULTS

The LOD-M participants had more vegetative symptoms at baseline. LOD-M exhibited greater cognitive decline but fewer residual depressive symptoms than EOD-M. Among participants who remained in the study for at least 1 year, in uncontrolled analyses, a greater percentage of LOD-M compared with EOD-M developed dementia (23.0% vs. 7.8%). Whereas in logistic analyses, controlling for baseline demographics, age at onset remained a predictor of dementia, the odds ratio suggested that the effect was relatively small.

CONCLUSIONS

The EOD-M and LOD-M participants have a different presentation and course. LOD-M may represent a syndrome of neuropsychiatric deterioration with expression of both depressive symptoms and cognitive decline.

Choosing treatment for depression in older adults and evaluating response

An update is provided on the current information regarding late life depression with regard to assessment, clinical implications, and treatment recommendations. Several treatments are considered evidence-based, but when deployed into field trials, the efficacy of these treatments falls short. It is thought that the lower impact in community trials is due in large part to patient, clinical, environmental, socio-economic, and cognitive correlates that influence treatment response. The aim is to assist providers in making decisions about what type of treatment to recommend based on a sound assessment of these clinical correlates.

Depressive symptoms in later life: differential impact of social support and motivational processes on depression in individuals with and without cognitive impairment

This study investigates the role of a motivational process based on a composite of four subcomponents (self-efficacy, decision regulation, activation regulation and motivation regulation), as a mediator of the relationship between social support and depression assessed with the Geriatric Depression Scale in cognitively impaired and unimpaired individuals. Participants were 229 adults with a mean age of 74 years (range: 52-94 years). The sample comprised 64 participants diagnosed with mild cognitive impairment (MCI), 47 participants diagnosed with early-stage Alzheimer's disease (AD), and a group of 118 participants without any cognitive impairment. In this cross-sectional study, bivariate correlations and linear regression models were used to assess the association between the predictor variables and depression. Linear regression models were controlled for age, gender, education, cognitive status, cognitive impairment and activities. In the total sample, social support (β = -0.15, p < 0.05) and motivational processes (β = -0.41, p < 0.001) were significantly associated with depression; the impact of social support was mediated by motivational processes. While motivational processes were associated with depression in all three groups (no impairment: β = -0.61, p < 0.001; MCI: β = -0.28, p < 0.05; early AD: β = -0.30, p < 0.06), social support lost significance (no impairment: β = -0.36, p < 0.001; MCI: β = 0.07, p = 0.59; early AD: β = -0.08, p = 0.62). Based on these findings, it can be argued that the impact of social support on depressive symptoms is attenuated by cerebral deterioration in cognitively impaired individuals, while motivational processes remain relevant.

The vascular depression hypothesis: mechanisms linking vascular disease with depression

The 'Vascular Depression' hypothesis posits that cerebrovascular disease may predispose, precipitate or perpetuate some geriatric depressive syndromes. This hypothesis stimulated much research that has improved our understanding of the complex relationships between late-life depression (LLD), vascular risk factors, and cognition. Succinctly, there are well-established relationships between LLD, vascular risk factors and cerebral hyperintensities, the radiological hallmark of vascular depression. Cognitive dysfunction is common in LLD, particularly executive dysfunction, a finding predictive of poor antidepressant response. Over time, progression of hyperintensities and cognitive deficits predicts a poor course of depression and may reflect underlying worsening of vascular disease. This work laid the foundation for examining the mechanisms by which vascular disease influences brain circuits and influences the development and course of depression. We review data testing the vascular depression hypothesis with a focus on identifying potential underlying vascular mechanisms. We propose a disconnection hypothesis, wherein focal vascular damage and white matter lesion location is a crucial factor, influencing neural connectivity that contributes to clinical symptomatology. We also propose inflammatory and hypoperfusion hypotheses, concepts that link underlying vascular processes with adverse effects on brain function that influence the development of depression. Testing such hypotheses will not only inform the relationship between vascular disease and depression, but also provide guidance on the potential repurposing of pharmacological agents that may improve LLD outcomes.

Heterogeneity of elderly depression: increased risk of Alzheimer's disease and Aβ protein metabolism

Epidemiological studies have proposed that depression may increase the risk for Alzheimer's disease (AD), even in patients with early-onset depression. Although metabolism of amyloid β protein (Aβ) in elderly depression received attention in terms of their correlation, there is a serious heterogeneity in elderly depression in terms of age at onset of depression. Moreover, it is unknown whether early-onset major depressive disorder (MDD) has a long-term effect on the involvement of Aβ metabolism and later development of AD. Thus, we evaluated serum Aβ40 and Aβ42 levels, the Aβ40/Aβ42 ratio in 89 elderly (≥60 years of age) inpatients with MDD and 81 age-matched healthy controls, and compared them among patients with early-onset (<60 years) and late-onset (≥60years) MDD and controls. The results showed that the serum Aβ40/Aβ42 ratio was significantly higher in patients with both early- and late-onset MDD than in controls (early-onset, p=0.010; late-onset, p=0.043), and it is of great interest that the serum Aβ40/Aβ42 ratio was negatively correlated with the age at MDD onset (R=-0.201, p=0.032). These results suggest that an earlier onset of MDD may have a more serious abnormality in Aβ metabolism, possibly explaining a biological mechanism underlying the link between depression and AD.

Abnormal functional connectivity of the default mode network in remitted late-onset depression

BACKGROUND

The functional neural network model has been a major method used to investigate mechanisms of neuropsychopathy. There is considerable evidence that late-onset depression (LOD) is the prodrome, or the early clinical manifestation, of Alzheimer's disease (AD). The default mode network (DMN) is one of the neural networks that can be used to explore the complex relationships between depressive symptoms, episodic memory deficits and other cognitive impairments. To date, no study has directly linked the DMN to LOD while focusing on episodic memory and the influence of apolipoprotein E4 (APOE4), a major genetic risk factor for AD in LOD patients.

METHODS

In total, 33 remitted LOD (rLOD) patients and 33 elderly controls underwent fMRI scanning using low-frequency BOLD signal imaging during the resting state and during an episodic memory task. Furthermore, function-based functional connectivities (FCs) in the region of interesting (ROI) (posterior cingulate cortex (PCC) of the DMN) were analysed to explore interactions between disease states, task states and genetic risk factors (APOE4).

RESULTS

Compared to healthy control subjects (HC), the FCs between the PCC and the right medial temporal lobe of the rLOD patients were significantly stronger during rest (p<0.005) and significantly weaker (p<0.05) during performance of the task. The mode of change from rest to task performance in the HC was in contrast to the mode of change in the rLOD patients. The FCs of the rLOD patients without APOE4 were significantly increased (p<0.05) in the resting state, but the rLOD patients who carried APOE4 showed a trend toward decreased FCs.

LIMITATIONS

The sample size was small. While the study was cross-sectional, we did not differentiate between the various types of antidepressants the patients used, which may have had different effects on cognitive function, especially on episodic memory.

CONCLUSION

Our results suggested that rLOD might be the prodrome, or the early clinical manifestation, of AD and that rLOD patients with APOE4 showed an increased risk for episodic memory decline and AD.

A longitudinal study of differences in late- and early-onset geriatric depression: depressive symptoms and psychosocial, cognitive, and neurological functioning

OBJECTIVES

Studies suggest early-onset depression (EOD) is associated with a more severe course of the depressive disorder, while late-onset depression (LOD) is associated with more cognitive and neuroimaging changes. This study examined if older adults with EOD, compared with those with LOD, would exhibit more severe symptoms of depression and, consistent with the glucocorticoid cascade hypothesis, have more hippocampal volume loss. A second goal was to determine if LOD, compared with EOD, would demonstrate more cognitive and neuroimaging changes.

METHOD

At regular intervals over a four-year period non-demented, older, depressed adults were assessed on the Mini-Mental Status Examination and the Montgomery-Asberg Depression Rating Scale. They were also assessed on magnetic resonance imaging.

RESULTS

Compared with LOD, EOD had more depressive symptoms, more suicidal thoughts, and less social support. Growth curve analyses indicated that EOD demonstrated higher levels of residual depressive symptoms over time. The LOD group exhibited a greater decrement in cognitive scores. Contrary to the glucocorticoid cascade hypothesis, participants with EOD lost right hippocampal volume at a slower rate than did participants with LOD. Right cerebrum gray matter was initially smaller among participants with LOD.

CONCLUSIONS

EOD is associated with greater severity of depressive illness. LOD is associated with more severe cognitive and neurological changes. These differences are relevant to understanding cognitive impairment in geriatric depression.

Exploring the pattern and neural correlates of neuropsychological impairment in late-life depression

BACKGROUND

Neuropsychological impairment is a key feature of late-life depression, with deficits observed across multiple domains. However, it is unclear whether deficits in multiple domains represent relatively independent processes with specific neural correlates or whether they can be explained by cognitive deficits in executive function or processing speed.

METHOD

We examined group differences across five domains (episodic memory; executive function; language skills; processing speed; visuospatial skills) in a sample of 36 depressed participants and 25 control participants, all aged ≥ 60 years. The influence of executive function and processing speed deficits on other neuropsychological domains was also investigated. Magnetic resonance imaging correlates of executive function, processing speed and episodic memory were explored in the late-life depression group.

RESULTS

Relative to controls, the late-life depression group performed significantly worse in the domains of executive function, processing speed, episodic memory and language skills. Impairments in executive function or processing speed were sufficient to explain differences in episodic memory and language skills. Executive function was correlated with anisotropy of the anterior thalamic radiation and uncinate fasciculus; processing speed was correlated with anisotropy of genu of the corpus callosum. Episodic memory was correlated with anisotropy of the anterior thalamic radiation, the genu and body of the corpus callosum and the fornix.

CONCLUSIONS

Executive function and processing speed appear to represent important cognitive deficits in late-life depression, which contribute to deficits in other domains, and are related to reductions in anisotropy in frontal tracts.

Clinical manifestations of geriatric depression in a memory clinic: toward a proposed subtyping of geriatric depression

BACKGROUND

As the older population increases so does the number of older psychiatric patients. Elderly psychiatric patients manifest certain specific and unique characteristics. Different subtypes of depressive syndromes exist in late-life depression, and many of these are associated with cognitive impairment.

MATERIALS AND METHODS

A total of 109 depressive patients and 30 normal subjects matched by age and educational level were evaluated using a neuropsychiatric interview and an extensive neuropsychological battery. Depressive patients were classified into four different groups by SCAN 2.1 (schedules for clinical assessment in Neuropsychiatry): major depression disorder (n: 34), dysthymia disorder (n: 29), subsyndromal depression (n: 28), and depression due to mild dementia of Alzheimer's type (n: 18).

RESULTS

We found significant associations (p<.05) between depressive status and demographic or clinical factors that include marital status (OR: 3.4, CI: 1.2-9.6), level of daily activity (OR: 5.3, CI: 2-14), heart disease (OR: 12.5, CI: 1.6-96.3), and high blood cholesterol levels (p:.032). Neuropsychological differences were observed among the four depressive groups and also between depressive patients and controls. Significant differences were observed in daily life activities and caregivers' burden between depressive patients and normal subjects.

CONCLUSION

Geriatric depression is associated with heart disease, high cholesterol blood levels, marital status, and daily inactivity. Different subtypes of geriatric depression have particular clinical features, such as cognitive profiles, daily life activities, and caregivers' burden, that can help to differentiate among them.

LIMITATIONS

The cohort referred to a memory clinic with memory complaints is a biased sample, and the results cannot be generalized to other non-memory symptomatic cohorts.

Early- and late-onset depression in the older: no differences found within the melancholic subtype

OBJECTIVE

Several studies have reported clinical and biological differences between early- and late-onset(EO and LO) depression, which suggest different underlying aetiological processes. The aim of the present study is to examine whether there are differences between EO and LO depressed patients with melancholy, controlling for current age, with regard to clinical variables, vascular risk factors and family history of affective disorders or suicide.

METHODS

One hundred and twenty-one melancholic patients were divided into three groups: patients with current age and onset earlier than 60 (N = 60), patients aged 60 or over and with onset at 60 or later(N = 30) and patients aged 60 or over and with onset before the age of 60 (N = 31). Systematic clinical data were collected with the structured interview ’The Schedule for Affective Disorders and Schizophrenia’. Symptom ratings at admission and at discharge were assessed by means of the 21-item Hamilton Depression Rating Scale, the Hamilton Anxiety Scale and the Widlöcher Depression Retardation Scale. Family history of affective disorders or suicide was obtained using the Family History Research Diagnostic Criteria. Vascular risk factors were also recorded.

RESULTS

The only symptoms that differed across the groups were feelings of anger and irritability, which scored lower in the LO older group. No other significant differences were found in the variables studied.

CONCLUSION

According to this study, LO depression with melancholia should not be considered as a distinct entity. Further studies on EO and LO-depression should consider this diagnostic subtype, among others, as a key variable.

Neuroanatomical and neuropsychological features of elderly euthymic depressed patients with early- and late-onset

BACKGROUND

Whether or not cognitive impairment and brain structure changes are trait characteristics of late-life depression is still disputed. Previous studies led to conflicting data possibly because of the difference in the age of depression onset. In fact, several lines of evidence suggest that late-onset depression (LOD) is more frequently associated with neuropsychological deficits and brain pathology than early-onset depression (EOD). To date, no study explored concomitantly the cognitive profile and brain magnetic resonance imaging (MRI) patterns in euthymic EOD and LOD patients.

METHOD

Using a cross-sectional design, 41 remitted outpatients (30 with EOD and 11 with LOD) were compared to 30 healthy controls. Neuropsychological evaluation concerned working memory, episodic memory, processing speed, naming capacity and executive functions. Volumetric estimates of the amygdala, hippocampus, entorhinal and anterior cingulate cortex were obtained using both voxel-based and region of interest morphometric methods. White matter hyperintensities were assessed semiquantitatively.

RESULTS

Both cognitive performance and brain volumes were preserved in euthymic EOD patients whereas LOD patients showed a significant reduction of episodic memory capacity and a higher rate of periventricular hyperintensities compared to both controls and EOD patients.

CONCLUSION

Our results support the dissociation between EOD thought to be mainly related to psychosocial factors and LOD that is characterized by increasing vascular burden and episodic memory decline.