Outcome of late-life depression after 3 years of sequential treatment

OBJECTIVE

To study the outcome of a sequential treatment protocol in elderly, severely depressed in-patients.

METHOD

All 81 patients from a 12-week double-blind randomized controlled trial (RCT) comparing venlafaxine with nortriptyline were asked to participate in a 3 year follow-up study. Thirty-two patients who did not achieve remission during the RCT, entered an open sequential treatment protocol and were treated with augmentation with lithium, switch to a monoamine oxidase inhibitor or ECT.

RESULTS

Seventy-eight of the 81 patients (96.3%) achieved a response [> or = 50% reduction in Montgomery Asberg Depression Rating Scale score) and 68 patients (84%) a complete remission (final MADRS score < or = 10) within 3 years of treatment. Greater severity and longer duration of the depressive episode at baseline predicted poor recovery. Augmentation with lithium may be the best treatment option in treatment resistant depressed elderly. Only few patients dropped-out due to side-effects.

CONCLUSION

Our study demonstrates the importance of persisting with antidepressant treatment in elderly patients who do not respond to the first or second treatment.

The relationship between characteristics of supported housing and the quality of life of older adults with severe mental illness

This study examined whether group living (as opposed to single living), staff availability and degree of personal freedom are associated with the quality of life of older adults with severe mental illness. A cross-sectional study was carried out in 18 supported living programmes in residential homes for the elderly that differed in terms of these three characteristics. The study included 35 patients with a psychotic disorder and 38 with an anxiety or mood disorder. Quality of life was assessed with the Philadelphia Geriatric Centre Morale Scale (PGCMS) and the Manchester Short Assessment of Quality of Life (MANSA). No association was found between group living and quality of life. Availability of psychiatrically trained staff was associated with life quality only for patients with a psychotic disorder, and perceived amount of personal freedom was associated with life quality only for patients with a non-psychotic disorder. Both differences were seen only on the PGCMS Agitation subscale. Older people with psychotic disorders appear to have relatively high needs for professional psychiatric support, and those with non-psychotic disorders for control over their daily lives. Further research is needed in other settings for older people with severe mental illness, preferably using longitudinal designs.

[A primary care program in old age psychiatry: background, implementation and first experiences]

The specific characteristics of elderly people, who are likely to develop somatic and psychiatric co-morbidity, and cognitive deterioration, require tailored support in primary care. The first results of a support programme for the elderly in primary care are encouraging. Further research will show whether the EPO has sufficient added value for both the GP and the patient to justify large-scale introduction.

Supported living in residential homes for the elderly: impact on patients and elder care workers

To enable older people with severe and persistent mental illness to live in the community, the Dutch mental health sector has developed a program for supported living in residential homes for the elderly. It provides for the permanent stationing of mental health workers (MHWs) in elder care facilities to support both the resident patients and the elder care staff. The authors examined associations between the number of MHW staff and the degree to which (1) patients were integrated into the community and (2) elder care workers had developed effective working alliances with their patients. Participants included 110 patients participating in 18 supported living programs in the Netherlands. Community integration was assessed in face-to-face interviews with the patients about their perceived influence over daily life, involvement in social activities, and social network size. The quality of the worker-patient relationship was assessed using the Dutch Working Alliance Questionnaire for Community Care, completed by the elder care worker primarily responsible for each patient. After differentiation of the MHW staff into medically trained and nurse-trained professionals, associations with outcome measures were found only for the nurse-trained staff. The more hours of nurse-trained staff capacity per patient, the more influence perceived by the patients, and the more directiveness shown by the elder care workers in their contacts with patients. The impact of supported living programs in residential homes for the elderly appears to be determined in part by the caseloads of the on-site MHWs.

Accuracy of the 15-item geriatric depression scale (GDS-15) in a community sample of the oldest old

BACKGROUND

Cognitive impairment is common in the oldest old. This might influence the sensitivity and specificity of the 15-item Geriatric Depression Scale (GDS-15). Few studies, however, have included subjects older than 85 years to evaluate the GDS-15 as a screening instrument for depression.

OBJECTIVE

To assess the sensitivity and specificity of the GDS-15 in a community sample of the oldest old.

METHODS

Seventy-nine subjects aged 85 and over were enrolled in the study. The GDS-15 and the Mini-Mental State Examination (MMSE) were administered by a trained interviewer. Within two days the Geriatric Mental State (GMS)/AGECAT, was administered to obtain a clinical diagnosis of depression.

RESULTS

Eight subjects (10%) were diagnosed with clinical depression. At a cut-off point of 3/4 the sensitivity and specificity of the GDS-15 were 88% and 76% respectively. In the group with MMSE scores of 28 and higher sensitivity was unaffected at all cut-off points while specificity increased. In the group with MMSE scores below 28 sensitivity was also unaffected at all cut-off points while specificity decreased.

CONCLUSION

The GDS-15 is a suitable instrument to diagnose depression in the general population of the oldest old. The optimal cut-off point depends on its intended use. In subjects with cognitive impairment the accuracy should be investigated further.

Apathy, anhedonia, and psychomotor retardation in elderly psychiatric patients and healthy elderly individuals

Normal aging of the brain affects the basal ganglia-thalamocortical circuits. These circuits are implicated in several neuropsychiatric disorders. Normal aging may therefore influence the symptomatology of psychiatric disorders in the elderly. We investigated motivational behavior that is associated with the function of these circuits, such as apathy, anhedonia, and psychomotor retardation in healthy elderly subjects and psychiatric inpatients (age > or = 60 yr). Apathy, anhedonia, and psychomotor retardation were assessed with the Apathy Evaluation Scale, the Snaith-Hamilton Pleasure Scale, and the Widlöcher Retardation Rating Scale. Other measurements included the Comprehensive Psychopathological Rating Scale, the Mini-Mental State Examination, and the assessment of vascular risk factors. We found some evidence for age-related changes in motivational behavior. In the healthy elderly group (n = 64), increasing age was associated with anhedonia, and in the patient group (n = 62), increasing age was associated with psychomotor retardation. Motivational disturbances could be the effect of an interaction between brain aging and the neuropathology of psychiatric disorders in the elderly.

Coping with depression and anxiety: preliminary results of a standardized course for elderly depressed women

The experiences of 51 elderly depressed female patients with a standardized course "Coping with Depression and Anxiety" were investigated. Preliminary findings concerning the effectiveness of this course in 34 patients who completed the course will also be presented. This course consisted of psychoeducation and skills training. Depressive symptoms were scored by using the SCL-90 depression scale and the Geriatric Depression Scale. Results indicate that patients were very enthusiastic about the course and that there was no need to make major changes in its structure and content. Also, depressive symptoms were significantly reduced after completion of the course, which emphasizes the importance of this psychoeducational program in the treatment of depression in elderly female patients.

[Cholinesterase inhibitors for Alzheimer disease: preliminary recommendations for treatment. Dutch Society for Psychiatry, Section of Geriatric Psychiatry]

Several cholinesterase inhibitors have recently become available for Alzheimer's disease. To reach consensus about their relevance and use in daily practice, a meeting with clinical experts was organised by the section of Geriatric Psychiatry of the Dutch Society for Psychiatry. So far, available drugs have only very modest effects on cognitive functioning and clinical impression, compared with placebo. The question whether these effects are clinically relevant cannot be answered yet. Awaiting the results of further studies, it was decided not to use cholinesterase inhibitors on a routine basis but to limit prescription of these drugs to research setting or under well-controlled conditions with regard to diagnosis and evaluation. Furthermore, prescription must be limited to mild or moderately severe dementia caused by 'probable Alzheimer's disease'. Proper evaluation in the individual patient is still an unresolved problem. Therefore, n = I protocols are to be designed. These should include the use of appropriate and standardised instruments measuring cognitive functions, behavioural functions and activities of daily life. The skills and experience required will be available in specialised and multidisciplinary units for dementia. Pharmaceutical treatment for Alzheimer's disease must be integrated with all other available forms of patient care.

[Revised consensus 'Diagnosis of the dementia syndrome']

Dementia is a clinical syndrome and is diagnosed on clinical grounds. Various types can be distinguished: the Alzheimer-type, frontal lobe dementia and subcortical dementia syndromes. Neuropsychological examination can contribute to the clinical diagnosis. Differentiation from delirium and depression, which may co-exist with dementia, is necessary. Once a dementia syndrome has been diagnosed its cause has to be ascertained. Alzheimer's disease is the most common cause and can often be diagnosed clinically. The clinical suspicion of vascular dementia has to be confirmed by imaging methods. Drug intoxication may cause or contribute to dementia. Blood tests should be performed routinely, but EEG, CT or MRI, SPECT and genetic tests can be carried out on clinical indication. Subsequently the need for care of the patient has to be established, as well as the ability of the carers to meet it. Regular follow-up is necessary. A definite diagnosis can only be made post-mortem when neuropathological examination has been performed. The organisation of diagnosis in the dementia syndrome should preferably take place in specialised multidisciplinary teams.

Treatment, outcome and predictors of response in elderly depressed in-patients

BACKGROUND

Full recovery rates in naturalistic studies of the treatment of elderly depressives are invariably lower than in clinical trials. This may be the result of inadequate treatment due to lack of clear treatment strategy recommendations for the elderly.

METHOD

This is a naturalistic prospective study of depressed elderly in-patients in three Dutch psychiatric hospitals. Patients were included when they suffered from any mood disorder according to DSM-III-R criteria. Severity of the depression was measured on the Montgomery-Asberg Rating Scale.

RESULTS

Antidepressants were prescribed to more than 90% of the patients. More than half of them received only one treatment. The dose of the antidepressants was less than the recommended dose for adults in 55% of cases. Full recovery from the depressive episode was achieved in less than half of the patients (33-45%).

CONCLUSIONS

In the present study a relatively poor outcome of the antidepressant treatment of elderly depressives has been found. A combination of low treatment expectations and fear of vigorous treatment seems to have been important.

A community based study of the incidence of dementia in subjects aged 85 years and over

The aim was to investigate the incidence rate of dementia for community residents aged 85 years and over. It was a two wave community study of 224 subjects (community residents including those residing in a nursing home) older than 85 years, restudied 4.1 years after a community prevalence study. A two stage method was used, comprising the mini mental state examination followed in a stratified sample by the geriatric mental state schedule (A3)/AGECAT. Incidence rates were based on person-years at risk. The overall incidence of dementia was 6.9 (95% confidence interval (95% CI) 4.8-9.1) per 100 person-years at risk. The incidence was significantly higher for women than for men; respectively 8.9 (95% CI 5.9-11.9) v 2.7 (95% CI 0.5-4.9) per 100 person-years at risk. In the fastest growing age group seven out of 100 persons develop dementia each year. Women, who constitute two thirds of the oldest old, seem to have a higher risk. Further research is needed into the risk factors for dementia in this age group.

Three-year follow-up of Mini-Mental State Examination score in community residents aged 85 and over

The objective of this study was to describe over time the course of cognitive function of elderly without cognitive impairment and of elderly with different stages of impairment, and to assess if the change in cognitive function was dependent on the initial level of function. The Mini-Mental State Examination (MMSE) was used at two time points. The first assessment (MMSE-1) was part of a community-based study and was obtained from 871 subjects. For the second assessment (MMSE-2) a sample of 166 subjects was drawn from the subjects alive at follow-up who had an MMSE-1 score. This sample was stratified by MMSE-1 score to avoid oversampling of subjects with high MMSE-1 scores. A second MMSE score was obtained from 134 elderly, whereas 18 subjects refused participation and 14 subjects were not traceable. The median age at first assessment was 89 years (25th percentile 87, 75th percentile 92), the mean follow-up period (S.D.) was 3.3 (0.5) years. The median change in MMSE score was minus 4 points (95% confidence interval (CI) -7 to -2) and the slope of the regression line of MMSE-2 on MMSE-1 was 1.1 (95% CI 0.9-1.3). It is likely that the slope was underestimated due to a floor effect, regression to the mean and missing observations. However, the probability of decline decreased if MMSE-1 was higher. Nevertheless, the probability ranged from 27 to 59% for subjects with the highest MMSE-1 scores aged 85 and 95 years respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

The prevalence of depression in elderly medical inpatients

To estimate the point-prevalence of major depression in elderly medical inpatients according to a computerized diagnostic system, a two-phase design was carried out. A consecutive series of 198 elderly medical inpatients completed two self-rating scales for depression (Beck Depression Inventory, Geriatric Depression Scale) and the Mini-Mental State Examination. According to these screening instruments, 69 'probable cases' were identified and were referred for psychiatric evaluation using the Geriatric Mental State Schedule. Only 10 patients were identified as diagnostic cases of depression according to the GMS-AGECAT package. The estimated prevalence rate for depression according to AGECAT in this population was 5.9% (95% confidence limits 2.3-9.3%). This is lower than has been found in previous studies in elderly medical inpatients. Possible reasons for this finding are discussed.

[The course of a clinically treated depression in the elderly]

A study was performed of the course of major depressions (DSM-III) of elderly people who had been admitted to a psychogeriatric ward of a general psychiatric hospital. Patients were selected by searching the files. Patients with another diagnosis on axis I or a serious physical illness were excluded. The selected patients were traced and asked to participate in a follow-up investigation. From the files 38 patients were selected, of whom three had died in hospital. The remaining 35 patients included 28 women and seven men, with an average age of 78 years. After discharge seven of them died a natural death and six patients refused to participate. The remaining 22 patients were visited. From the files it appeared that 54% had completely recovered at discharge. Patients with a delusional depression had been hospitalised significantly longer, had been treated with more medicines and had less often been completely recovered at discharge. At the time of the follow up 64% had completely recovered but 32% had had a relapse. Patients with a delusional depression less often recovered completely. A remarkably low percentage of the population studied were able to live on their own. The results of this study are compared with foreign studies.

[Psychiatric disorders in elderly patients admitted in a general hospital]

STUDY OBJECTIVE

To determine the prevalence of psychiatric disorders, especially depressive illness, in elderly medical inpatients.

SETTING

University Hospital Leiden.

DESIGN

Two-stage design.

PATIENTS AND METHODS

In six somatic wards a series of 250 patients were randomly selected and screened with two self-rating scales for depression (Beck Depression Inventory, Geriatric Depression Scale) and one screening scale for cognitive dysfunctions (Mini-Mental State Examination). The 52 drop-outs differed significantly from the other patients only in a greater general illness severity, and a higher prevalence of a psychiatric history. Eighty-two patients were selected for a diagnostic procedure with a standardised, semi-structured psychiatric interview, and were classified according to the DSM III-R. Fifty-nine of them were probable cases according to the screening instruments, 23 were selected at random from the probable non-cases.

RESULTS

A psychiatric disorder was detected in 25 patients, all but one patient with schizophrenia were found in the group of probable cases. Only five patients were classified as major depression, which lead to a prevalence rate of 2.9% (95% CI 0.4-5.4%). We found evidence of many psychiatric disorders in the group of 52 drop-outs, but these were mostly organic psychiatric disorders, and just one mood disorder.

CONCLUSION

The prevalence of major depression is lower than found until now among elderly medical inpatients.

The general population prevalence of non-organic psychiatric disorders in subjects aged 85 years and over

The prevalence of psychiatric disorders was investigated in all inhabitants over 85 years of age (N = 1259), residing in Leiden, The Netherlands. The study design consisted of two phases. In the first phase the Mini-Mental State Examination (MMSE) and the 12-item version of the General Health Questionnaire (GHQ-12) were used to screen for potential cases; in the second phase all potential cases and a sample of the non-cases were interviewed with the Geriatric Mental State Schedule (GMS). DSM-III diagnoses were made based on the GMS and on information obtained from caregivers. There was a high prevalence of organic disorders of 31% (95% CI: 27-35%). The estimated overall prevalence rate for functional disorders was 8% (95%) CI: 4-12%). This is an underestimate because organic and functional disorders are mutually exclusive in DSM-III. The prevalence rate estimated for the population at risk for functional disorders (i.e. the total population minus the organic cases) was 12% (95% CI: 6-18%). This is very similar to prevalence rates for functional disorders found in population based surveys in younger age groups. Therefore, in contrast with the dementias, there appears to be no increase with age for the functional disorders.

A community-based study of survival in dementia

The objective of this study was to compare the mortality rate of demented and nondemented subjects in a single cohort. We followed up a cohort of subjects comprising all 1259 inhabitants of Leiden aged 85 years and over, evaluated earlier for the presence of dementia, and including institutionalized subjects. The main outcome measure was the mortality rate ratio of the demented and nondemented groups adjusted for age and sex. The mortality rate ratio of the demented vs the nondemented group was 1.9 (95% confidence interval: 1.7-2.2). No difference in mortality rate was found between those with mild vs moderate to severe dementia. The mortality rate in dementia patients is higher than in nondemented subjects.

[Prevalence of the dementia syndrome in the oldest residents of a somatic nursing home]

OBJECTIVE

To estimate the prevalence of dementia among subjects of 85 years and over residing in a somatic nursing home.

DESIGN

A two-phase design with the mini-mental state examination (MMSE) in the screening phase and the geriatric mental state schedule (GMS) in the diagnostic phase.

SETTING

Three somatic nursing homes in Leiden.

SUBJECTS

All subjects aged 85 years and over residing in one of the three nursing homes on December 1, 1986. First phase participation rate was 75%; second phase participation rate was 88%.

MAIN OUTCOME MEASURE

DSM-III diagnosis of dementia without further specification of the aetiology of the dementia.

RESULTS

An overall prevalence of 54% (95% CI: 43-66%) was found. This included 32% mild dementia, 9% moderate and 13% severe dementia.

CONCLUSION

Dementia was found to be the most prevalent disorder among somatic nursing home residents aged 85 years and over. The shortage of psychogeriatric nursing home beds may have contributed to this high prevalence of dementia. However, the relatively large number of mild cases, which are usually not listed for admission to a psychogeriatric nursing home, indicates that the combination of a beginning dementia with physical impairment led to admission to a somatic nursing home. Considering the growth of the oldest part of the population it is to be expected that the prevalence of dementia will remain high among the oldest residents of somatic nursing homes.

The prevalence of vascular dementia in Europe: facts and fragments from 1980-1990 studies. EURODEM-Prevalence Research Group

We selected, reanalyzed, and compared data from current prevalence studies of vascular dementia in Europe. Inclusion criteria were: dementia defined by the Diagnostic and Statistical Manual for Mental Disorders, edition 3, or equivalent criteria; case finding through direct individual examination; appropriate sample size; and inclusion of institutionalized persons. Mixed dementia was combined with vascular dementia. Of the 23 surveys of dementia considered, five fulfilled the inclusion criteria. Age-specific prevalence varied more widely for men than for women; differences were greater in older ages. The prevalence increased steeply with advancing age in all countries, and was generally higher in men; it declined over 15 years in the age class of 80 to 89 years in one Swedish population. Within populations, Alzheimer's disease was generally more common than vascular dementia. Unfortunately, prevalence studies of vascular dementia are limited in Europe and worldwide, and their comparison is impeded by the lack of common diagnostic criteria.

Frequency and distribution of Alzheimer's disease in Europe: a collaborative study of 1980-1990 prevalence findings. The EURODEM-Prevalence Research Group

We reanalyzed and compared current prevalence estimates of Alzheimer's disease in Europe. Studies characterized as follows qualified for comparison: dementia defined by the Diagnostic and Statistical Manual for Mental Disorders, 3rd edition, or equivalent criteria; Alzheimer's disease diagnosed by the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association or equivalent criteria; case-finding through direct individual examination; appropriate sample size; and inclusion of institutionalized persons. Of the 23 European surveys of dementia considered, six fulfilled the inclusion criteria. When age and sex were considered, there were no major geographic differences in the prevalence of Alzheimer's disease across Europe. Overall European prevalence (per 100 population) for the age groups 30 to 59, 60 to 69, 70 to 79, and 80 to 89 years was, respectively, 0.02, 0.3, 3.2, and 10.8. Prevalence increased exponentially with advancing age and, in some populations, was consistently higher in women. Prevalence remained stable over 15 years in one study.

Prevalence of dementia in the 'oldest old' of a Dutch community

OBJECTIVE

To estimate the prevalence rate of dementia in subjects 85 years of age and over.

DESIGN

A two-phase design with the Mini-Mental State Examination (MMSE) in the screening phase and the Geriatric Mental State Schedule (GMS) in the diagnostic phase.

SETTING

Community survey including subjects in residential care.

SUBJECTS

All (n = 1,259) inhabitants of Leiden, The Netherlands, aged 85 years and over on December 1, 1986. First phase participation rate was 71% (17% dropout due to death); second phase participation rate was 82%.

MAIN OUTCOME MEASURE

DSM-III diagnosis of dementia without further specification of the etiology of the dementia.

RESULTS

An overall prevalence rate of 23% (95% C.I.: 19%-26%) was found. This included 12% mild dementia, 7% moderate and 4% severe dementia. The prevalence rate was higher among women (24%) than among men (18%). It increased with age from 19% (95% C.I.: 16%-22%) in the group of 85-89 years to 32% (95% C.I.: 26%-39%) in the group of 90-94 years to 41% (95% C.I.: 25%-58%) in the 95+ group.

CONCLUSION

A fifth of the 85+ and a third of the 90+ population suffer from dementia with an indication that half of the 95+ population is affected. With the expected steep rise in the number of the oldest old, dementia will stay a major health problem in the near future.

Alcohol abuse among elderly patients in a general hospital as identified by the Munich Alcoholism Test

The aim of this study was to assess the prevalence of alcohol abuse among elderly patients in a general hospital. Scores on the Dutch version of the Munich Alcoholism Test (MALT) and medical records were obtained from 132 patients aged 65 and over, staying at the University Hospital Leiden. According to the MALT, 9% of the elderly patients (13% of the men and 7% of the women) were classified as alcoholics. In contrast, the discharge diagnosis involved alcohol dependence or abuse for only 0.5% of the patients 65 years and over admitted in 1989. In this study, two thirds of the alcoholic patients were recognized by the attending physician. Vague symptoms as admission diagnosis occurred more frequently in alcoholics than in nonalcoholics. Regarding former medical diagnoses, alcoholics had suffered significantly more often from organic brain diseases. In comparison to nonalcoholics, elderly alcoholics used more psychotropic drugs.

Reference values for the Mini-Mental State Examination (MMSE) in octo- and nonagenarians

The Mini-Mental State Examination (MMSE) was used in a population survey of all inhabitants of Leiden, the Netherlands, over 85 years (n = 1258). In this paper we report on 532 subjects without neurological or psychiatric disease. Results show that the median score and lowest quartile cut-off score remain high until the tenth decade (median score = 28, lowest quartile cut-off score = 26). Thus age, in itself, is not a major limitation in using the MMSE. In this study a comparatively low level of education (the majority had 6 to 7 years of education) did not affect the results on the MMSE in a negative way, nor did we find an association with the use of psychoactive drugs.