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The question of what constitutes a dignified old age has always been a topic of philosophical enquiry. Already in the writings of the stoic philosophers we can find relevant contributions to an ethic of “successful” aging. Seneca, for instance, reflects upon the pleasures of old age in several of his famous “Letters to Lucilius” (Seneca, 1967). However, he also writes about the bad years that may lie ahead and confides to his pupil: “Do not hear me with reluctance as if my statement applied directly to you, but weigh what I have to say. It is this. I shall not abandon old age, if old age preserves me intact for myself, and intact as regards to the better part of myself; but if old age begins to shatter my mind, and pull its various faculties to pieces, if it leaves me, not life, but only the breath of life, I shall rush out of a house that is crumbling and tottering . . .”
Background: We assessed the relationship between cognitive impairment (including mild cognitive impairment with no signs of dementia, and dementia) and risk for depression in old age (60 years and older).
Methods: MEDLINE, EMBASE and the Cochrane Library database were used to identify potential studies. All of the clinical studies that produced data on the association between cognitive function and risk of depression among individuals aged 55 years or older were identified and included in this review. The studies were classified into cross-sectional and longitudinal subsets. The quantitative meta-analysis of cross-sectional and longitudinal studies were performed. For prevalence and incidence rates of depression, odds risk (OR) and relative risk (RR) were calculated, respectively.
Results: Since all but two studies found in the search were for individuals aged 60 years or over, we assessed and reported on results for this larger group only. In this review we included 13 cross-sectional and four prospective longitudinal studies. The quantitative meta-analysis showed that, in old age, individuals with non-dementia cognitive impairment had neither significant higher prevalence nor incidence rates of depression than those without (odds risk (OR): 1.48, 95% confidence intervals (95% CI): 0.87–2.52; relative risk (RR): 1.12, 95% CI: 0.62–2.01). In old age, individuals with dementia had both significant higher prevalence and incidence rates of depression than those without (OR: 1.82, 95% CI: 1.15–2.89; RR: 3.92, 95% CI: 1.93–7.99).
Conclusions: Despite the methodological limitations of this meta-analysis, we found that in old age, there was no association between depression and cognitive impairment with no dementia; however, there was a definite association between depression and dementia and thus dementia might be a risk for depression.
Background: Mild cognitive impairment (MCI) is commonly associated with memory impairment. There have been a number of studies attempting to ameliorate this through memory interventions including memory rehabilitation and training. The current paper reviews the evidence for the effectiveness of such interventions in enhancing learning of specific information, their impact on untrained material, compensation for memory impairment and improving everyday functioning.
Methods: The literature was systematically searched for studies focusing on interventions targeting memory impairment in MCI using relevant search terms. Studies were screened for inclusion or exclusion using a priori criteria and, once identified, studies were examined for quality using pre-specified criteria.
Results: A total of 226 studies were identified in the search, ten of which were included in the final review. Only one study was an RCT of “adequate” methodology. It was tentatively suggested that people with MCI can learn specific information, although there was little evidence to suggest that memory training can generalize. There was some limited evidence of ability to learn to compensate for memory difficulties and contradictory findings regarding improvement in everyday life.
Conclusions: The poor methodological quality of the included studies implies that the ability to draw conclusions is limited. MCI is a controversial concept and there is a need for good quality trials examining the efficacy of memory interventions. There are some indications that memory impairment in MCI might best be targeted by interventions developing compensatory strategies and targeting the learning of specific information relevant to the individual.
Background: Cholinesterase inhibitors (ChEIs) are being used for increasingly long periods of time, even in patients with severe Alzheimer's disease. Because there is little data to help clinicians to decide on when it is safe and appropriate to discontinue ChEIs after long-term use, practices may vary widely.
Methods: An internet-based survey was undertaken of Canadian dementia experts (geriatric psychiatrists, neurologists, geriatricians) involved in clinical trial research. Recommendations for ChEI discontinuation were determined based on responses to questions dealing with patient/caregiver preference, administrative considerations, effectiveness, and adverse events.
Results: There was reasonable consensus that ChEIs should be discontinued based on patient and caregiver preference, and in the presence of severe bothersome adverse events. There was much less consensus on issues related to effectiveness – in particular, what constitutes greater than expected decline. There was a general reluctance to rely on any single measure of cognition, function and/or behavior, and in particular, the MMSE was seen as unhelpful for making decisions about discontinuation.
Conclusion: Recommendations for discontinuing ChEIs after long-term use from a survey of dementia experts are presented. Ideally, clinical practice guidelines based on controlled discontinuation trials are needed.
Background: The Kana Pick-out Test (KPT), which was developed in Japan, is suitable for evaluating frontal lobe function and screening for mild dementia. However, the neural substrates involved remain to be elucidated. The aim of the present study was to identify the regional perfusion patterns in the brain associated with performance scores on the KPT in patients with mild Alzheimer's disease (AD), using brain perfusion assessed by single photon emission computed tomography (SPECT).
Methods: Twenty AD patients with high scores on the KPT and 20 age- and sex-matched AD patients with low scores were selected from 227 consecutive Japanese patients of the Memory Clinic of Okayama University Hospital. All 40 subjects underwent brain SPECT with 99mTc-ethylcysteinate dimer, and the SPECT images were analyzed by Statistical Parametric Mapping.
Results: With the exception of KPT scores, no significant differences were found between high and low scoring groups with respect to Addenbrooke's Cognitive Examination scores, Mini-mental State Examination scores, or the depression score of the Neuropsychiatric Inventory subscale. Compared to patients with high scores on the KPT, AD patients with low scores on the KPT showed significant hypoperfusion in the left subgenual cingulate gyrus (SGC) extending to the right SGC.
Conclusions: Our results suggest that functional activity of the SGC is closely related to scores on the KPT. KPT might be a promising strategy to use in detecting early stages of AD with low SGC function.
Background: The economic cost of dementia is high and can be predicted by cognitive and neuropsychiatric profiles. The differential costs of the various subtypes of dementia are unknown in Argentina, and this study therefore aimed to compare these costs.
Methods: Patients with a diagnosis of dementia of Alzheimer-type (DAT), frontotemporal dementia (FTD) and vascular dementia (VaD), and their primary caregivers, were evaluated between 2002 and 2008.
Results: 104 patients with dementia (DAT = 44, FTD = 34, VaD = 26) were screened and matched by age and educational level with 29 healthy subjects. Demographic variables showed no significant differences among dementia patients. The annual direct costs were US$4625 for DAT, US$4924 for FTD, and US$5112 for VaD (p > 0.05 between groups). In the post hoc analysis VaD showed higher hospitalization costs than DAT (p < 0.001). VaD exhibited lower medication costs than FTD (p < 0.001). DAT exhibited higher anti-dementia drug costs; FTD had higher psychotropic costs. In the multivariate analysis, depression, activities of daily living, and caregiver burden were correlated with direct costs (r2 = 0.76).
Conclusions: The different dementia types have different costs. Overall, costs increased with the presence of behavioral symptoms, depression and functional impairment of activities of daily living.
Background: Informal, unpaid, and lifelong older caregivers of adults with intellectual disabilities (ID) are usually female and most often are mothers of adults with ID. However, research exploring different predictors of subjective and objective burden among these older female caregivers is sparse. The objective of this study was to examine whether the subjective and objective burden as well as positive appraisals are predicted by the same or different variables linked to the caregivers and the adults with ID.
Methods: Face-to-face interview questionnaires were administered in a city in Taiwan in 2006–2007 and 350 female family caregivers aged 55 years and older completed the interview in their homes. The independent variables included adult care demands and caregiver variables, while the dependent variables were caregivers’ subjective burden, caregivers’ objective burden and caregivers’ positive appraisals.
Results: The results demonstrated that adult care demands were associated more with the objective than the subjective caregiving burden. The strongest predictors of both subjective and objective burden were the care recipient's instrumental activities of daily living functionality, caregiver's age, and caregiver's health status. The significant predictors for positive caregiving appraisals were the caregiver's age and the caregiver's level of social support.
Conclusions: The results indicate that both the subjective and objective burdens were mostly related to the same factors, that is, to the characteristics of the older female caregivers and the recipients of care with ID. On the other hand, positive attitudes towards caregiving roles were only associated with caregiver variables.
Background: Although research has highlighted the importance of including cultural factors in the analysis of caregiver stress, little is known about the effects of motives for caregiving on the stress and coping process. This study is aimed at analyzing the dimensional structure of the Cultural Justifications for Caregiving Scale – Revised (CJCS-R), and the effects of motives for caregiving on stressors, caregiver resources and outcome variables.
Methods: Dementia caregivers (N = 166) were interviewed and the following variables were assessed: motives for caregiving (CJCS-R), stressors (frequency of behavioral problems), resources (rumination, cognitive reappraisal), and outcomes (depression, anxiety and anger).
Results: A bidimensional structure was obtained for the CJCS-R, and the two factors were labeled Intrinsic and Extrinsic motives for caregiving. Participants were divided into four groups corresponding to four motivation profiles: HIHE = High Intrinsic Motives + High Extrinsic motives; LILE = Low Intrinsic Motives + Low Extrinsic Motives; HILE = High Intrinsic Motives + Low Extrinsic Motives; and LIHE = Low Intrinsic Motives + High Extrinsic Motives. No differences between groups were found in frequency of behavioral problems. Caregivers in the LIHE group had significantly worse consequences on caregiver resources and outcome variables compared to the other groups.
Conclusions: The results support the usefulness of considering motives for caregiving as a multidimensional construct. Analyzing caregivers' motivation profiles may constitute a useful strategy for identifying caregivers at risk. Caregivers scoring simultaneously low on intrinsic motives and high on extrinsic motives may be at particular risk for negative caregiving outcomes.
Background: The age-prospective memory-paradox describes the general pattern of age-related deficits in laboratory-based prospective memory tasks and age-related benefits in naturalistic tasks that are carried out in participants' everyday lives. However, the mechanisms which are critical in determining the direction of age effects remain poorly delineated.
Method: Twenty young and 20 old adults performed a laboratory and a naturalistic prospective memory task, which were similar in structure and demand. Several factors highlighted in recent theoretical models as potentially important to understanding the paradox (motivation, metacognitive awareness, activity absorption, control over the task) were assessed and their contribution to the age paradox empirically explored.
Results: First, analyzing mean level age differences, the paradox was confirmed. Second, exploring possible correlates of the paradox revealed that, while low levels of daily activity absorption, high motivation and good metacognitive awareness were associated with age benefits in prospective memory performance in the naturalistic task, high ongoing activity absorption and low control over the prospective memory cue seem important for understanding age deficits in lab-based tasks.
Conclusion: The current study confirms the age-prospective memory-paradox within one sample and with carefully matched laboratory and naturalistic tasks. Additionally, it takes an important step forward in clarifying the role of different factors in understanding age effects across these different contexts. The results indicate that the relative importance of different factors vary as a function of assessment context, with conceptual as well as applied implications.
Background: Low education and illiteracy are associated with an increased risk of dementia. This study aimed to develop a neuropsychological test battery applicable to both illiterate and literate elderly and to assess its reliability and validity for a diagnosis of dementia.
Methods: We developed the Literacy Independent Cognitive Assessment (LICA), which consists of 13 subtests assessing memory, language, visuoconstruction, executive function, attention and calculation. We investigated its reliability and validity on 152 patients with dementia, 66 with mild cognitive impairment and 639 normal controls.
Results: The subtests were found to be applicable to most of the illiterate normal controls (97.3%) and were found to have high inter-rater reliabilities (r = 0.85–1.00, p < 0.001) and moderate to high test-retest reliabilities (r = 0.50–0.86, p < 0.001). The LICA performed well in discriminating participants across Clinical Dementia Rating stages and showed excellent internal consistency and good concurrent validity with the Korean Mini-mental State Examination in both literate and illiterate participants. The area under the curve of the receiver operating characteristic was 0.985 in each of the two literacy groups. Sensitivity and specificity of the LICA to make a diagnosis of dementia was 91.9% and 91.8% at the cutoff point of 186.0 in the literate subjects and 96.2% and 91.1% at the cutoff point of 154.5 in the illiterate subjects. The battery was factored into two separate factors consisting of verbal memory tests and tests for other cognitive domains.
Conclusion: The LICA is a valid and reliable instrument for a diagnosis of dementia in both illiterate and literate elderly.
Background: Previous studies have reported that nurse detection of delirium has low sensitivity compared to a research diagnosis. As yet, no study has examined the use of nurse-observed delirium symptoms combined with research-observed delirium symptoms to diagnose delirium. Our specific aims were: (1) to describe the effect of using nurse-observed symptoms on the prevalence of delirium symptoms and diagnoses in long-term care (LTC) facilities, and (2) to compare the predictive validity of delirium diagnoses based on the use of research-observed symptoms alone with those based on research-observed and nurse-observed symptoms.
Methods: Residents aged 65 years and over of seven LTC facilities were recruited into a prospective study. Using the Confusion Assessment Method (CAM), research assistants (RAs) interviewed residents and nurses to assess delirium symptoms. Delirium symptoms were also abstracted independently from nursing notes. Outcomes measured at five month follow-up were: death, the Hierarchic Dementia Scale (HDS), the Barthel ADL scale, and a composite outcome measure (death, or a 10-point decline in either the HDS or the ADL score).
Results: The prevalence of delirium among 235 LTC residents increased from 14.0% (using research-observed symptoms only) to 24.7% (using research- and nurse-observed symptoms). The relative risks (and 95% confidence intervals) for prediction of the composite outcome, after adjustment for covariates, were: 1.43 (0.88, 1.96) for delirium using research-observed symptoms only; 1.77 (1.13, 2.28) for delirium using research- and nurse-observed symptoms, in comparison with no delirium.
Conclusions: The inclusion of delirium symptoms observed by nurses not only increases the detection of delirium in LTC facilities but improves the prediction of outcomes.
Background: This study explored the relationship between “worthlessness” and all cause non-suicide mortality in Chinese elderly men.
Methods: Data from interviews of 1999 men aged 65 years and over were collected. Clinically significant depressive symptoms were measured using the validated Chinese version of Geriatric Depression Scale. “Worthlessness” was defined by one of the 15 questions from the Geriatric Depression Scale with a yes/no response. All-cause mortality over six years was collected using data from the National Death Registry with adjudication by 4-monthly telephone interviews. Two men were excluded after suicide death.
Results: Age-adjusted mortality rates at five years were 44.3 and 23.9 per 1,000 person years for those who felt “worthless” and those did not, respectively. The adjusted relative risk for all-cause mortality associated with feeling worthless was 1.34 (95% CI: 1.02–1.76) after adjusting for potential confounders that included age, marital status, education, smoking, alcohol consumption, number of chronic diseases, self-rated health, body mass index, cognitive status, physical activity, occupation and maximum lifetime income. There was no statistically significant association between other depressive symptoms or overall depression and mortality.
Conclusion: Worthlessness may be independently associated with all-cause mortality in Chinese elderly men.
Background: Multimorbidity has been suggested to be associated with a variety of negative health-related outcomes. The present study was designed to evaluate the association between multimorbidity and subjective memory complaints.
Methods: This cross-sectional study was based on data obtained from a postal survey designed by the Public Health Service (Gemeentelijke Gezondheids Dienst, GGD) involving 15,188 persons aged 55 years and over living independently in Limburg, the Netherlands. Multivariate logistic regression analyses, adjusted for potentially important covariates, were performed to evaluate the association between self-reported multimorbidity and three outcomes related to subjective memory complaints.
Results: Multimorbidity was indeed related to subjective memory complaints. The association between multimorbidity and subjective memory complaints was positively influenced by age. Moreover, multimorbidity was related to the degree of worrying about memory complaints in people who perceived themselves as forgetful. Multimorbidity was also associated with reporting a larger increase in these subjective memory complaints during the past year. In this latter case, multimorbidity had more prognostic capability in men than in women. Psychological distress was related to all three subjective memory-related outcome measures.
Conclusions: In our sample, which was representative of the Dutch population, multimorbidity was associated with subjective memory complaints. The relationship between multimorbidity and subjective memory complaints differed between men and women and between age groups.
Background: Social engagement and depression are important outcomes for residents with dementia in long-term care. However, it is still largely unclear which differences in social engagement and depression exist in residents of various long-term care settings and how these differences may be explained. This study investigated the relationship between social engagement and depressive symptoms in long-term care dementia units, and studied whether differences in social engagement and depressive symptoms between units can be ascribed to the composition of the resident population or to differences in type of care setting.
Methods: Thirty-seven long-term care units for residents with dementia in nursing- and residential homes in the Netherlands participated in the study. Social engagement and depressive symptoms were measured for 502 residents with the Minimum Data Set of the Resident Assessment Instrument. Results were analyzed using multilevel analysis.
Results: Residents of psychogeriatric units in nursing homes experienced low social engagement. Depressive symptoms were most often found in residents of psychogeriatric units in residential homes. Multilevel analyses showed that social engagement and depressive symptoms correlated moderately on the level of the units. This correlation disappeared when the characteristics of residents were taken into account.
Conclusions: Social engagement and depressive symptoms are influenced not only by individual characteristics but also by the type of care setting in which residents live. However, in this study social engagement and depressive symptoms were not strongly related to each other, implying that separate interventions are needed to improve both outcomes.
Background: The capacity of friends and family member informants to make judgments about the presence of a mood disorder history in an older primary care patient has theoretical, clinical, and public health significance. This study examined the accuracy of informant-reported mood disorder diagnoses in a sample of primary care patients aged 65 years or older. We hypothesized that the accuracy (sensitivity and specificity) of informant reports would vary with the patient's personality.
Methods: Hypotheses were tested in 191 dyads consisting of patients and their friends or relatives (informants) recruited from primary care settings. Gold-standard mood disorder diagnoses were established at consensus conferences based on a review of medical charts and data collected in a structured interview with the patient. Patients completed an assessment battery that included the NEO-Five Factor Inventory.
Results: Sensitivity and specificity of informant-derived mood disorder diagnoses were related to patient personality. Sensitivity of informant-derived lifetime mood disorder diagnoses was compromised by higher Extraversion and higher Agreeableness. Specificity of informant-derived lifetime mood disorder diagnoses was compromised by lower Agreeableness and higher Conscientiousness.
Conclusion: Patient personality has implications for the accuracy of mood disorder histories provided by friends and family members. Given that false negatives can have grave consequences, we recommend that practitioners be particularly vigilant when interpreting collateral information about their extraverted, agreeable patients.
Background: The “vascular depression” hypothesis has sought to explain differences in etiology between early and late life depression, and has been reinforced by recent imaging and morphometric studies. Gamma-aminobutyric acid (GABA) is thought to play a major role in the neurobiology of depression. However, it is unclear whether there is an effect on GABA neuronal subpopulations in an elderly depressed cohort. This study therefore examined immunohistochemically two calcium-binding proteins, calretinin and parvalbumin, which have been demonstrated to bind to two distinct GABAergic interneuron subpopulations, within the dorsolateral prefrontal cortex (DLPFC) of elderly depressed patients, against age-matched controls.
Methods: Post-mortem tissue was obtained from nine controls and 11 depressed patients for the parvalbumin study and seven controls and 14 depressed patients in the calretinin study, and the mean percentage per area of immunohistochemical staining of the two antibodies was measured in individual layers and across the whole of the DLPFC.
Results: The study found a reduction in parvalbumin immunostaining in layer 6 (p = 0.05) of the DLFPC in elderly depressed patients. However, no significant changes were found in parvalbumin or calretinin immunostaining in the any other layer of the DLPFC in elderly depressed patients.
Conclusion: The study does not suggest any change in GABA interneuron subpopulations, though significant reductions in layer 6 may represent subtle disturbance in GABA parvalbumin-expressing interneuron and glumatatergic pyramidal projection neuron regulation in late-life depression.
Background: The aim of this study was to identify long-term effects of diagnostic criteria on the Post Traumatic Stress Disorder Checklist (PCL-C) for a test group of Finnish evacuees from World War II and compare the outcome effect with a control group of children who lived in Finland during the war in 1939–1945.
Methods: 152 participants were recruited by the local leader of the Finnish War Child Association in Sweden and Finland. The selected group answered questions on the Post Traumatic Stress Disorder Checklist (PCL-C) and the EMBU (Swedish acronym for “Own Memories of Parental Rearing”).
Results: Evidence suggests a link between childhood parental separation and termination of the internalized attachment hierarchy of origin in a detachment process among Finnish evacuees. Based on the Post Traumatic Stress Disorder Total (PCL-C) diagnosis an extreme traumatization for 36.7% of the test group subjects was identified, including a hidden Holocaust trauma in the population of Finnish evacuees.
Conclusions: The study met the criteria for satisfying global evidence value. Sixty-five years after the end of World War II and in line with other studies on war children, the data show high levels of different trauma exposures from the war with 10.6 higher risk (odds ratio) for the exposed group of Finnish evacuees. Despite some limitations, the data highlight the need for further investigation into different parts of the detachment process among seriously traumatized groups to reveal resilience and other dimensions of importance in professional mental health creation.
This case describes the differential diagnosis and treatment of a 70-year-old man with an avoidant personality disorder. It illustrates that diagnostic assessment and treatment of personality problems in the elderly are possible in mental health care. It demonstrates that multiple stand-alone treatment modules can form part of a single course of adaptation-focused treatment of personality disorders. An interpersonal approach forms an important basis for tackling the typical interpersonal difficulties that occur in axis-II disorders.
Neurosyphilis can present with psychiatric symptoms. The late form can occur in old age with psychosis, paranoid delusions, affective disorders or cognitive impairment. Here we present a case of neurosyphilis in an elderly woman who, over six months, progressively manifested personality changes and paranoid delusions which were initially suspected as Alzheimer's disease. Psychotic symptoms showed a good response to antibiotic treatment. We conclude that neurosyphilis is a relevant differential diagnosis in patients developing severe psychiatric symptoms in old age. As a causal antibiotic treatment is possible this infectious disease should be considered seriously in gerontopsychiatric patients.
Lapid et al. (2010) provide a fascinating insight into the much over-looked problem of eating disorders (EDs) in older adults and highlight the fact that an ED is often not considered in our differential when assessing elderly patients.