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In the eldery population anti-epileptic drugs (AED) are used in epilepsy, neuralgiform pain, psychiatric disorders and behavioral problems in dementia. The prevalence of AED- treatment in the community is 1%; among nursing home residents 10%. A complex of adverse effects, known as Drug Reaction Eosinophilia and Systemic Symptoms (DRESS), is associated with several drugs, in particular AED. The incidence of DRESS syndrome is estimated between 1 in 1000 and 1 in 10000. DRESS syndrome has a high mortality rate (around 10%), primarily due to doctor's delay in recognition.
As AED-induced DRESS syndrome is rarely described in elderly patients, we describe two with dementia-related behavioural problems, treated with carbamazepine. Both patients developed severe rash, eosinophilia and fever after three weeks of administration. Patient 1 also developed anemia, diarrhoea and delirium; Patient 2 suffered from a severe edema of arms and face. Initially the clinical presentation of inflammatory and hypersensitivity symptoms was attributed to several diseases and/or medication other than carbamazepine. After recognition of DRESS by carbamazepine and stopping this drug, both patients fully recovered.
Recognition of DRESS syndrome induced by AED is difficult as the condition is rare, symptoms occur 1 to 8 weeks after start of treatment; there may be slow progression and similarity with infections and neoplastic disorders exists. Withdrawal of the offending drug is the primary treatment of the DRESS syndrome and patients relatives must be informed since the incidence of the DRESS syndrome is higher amongst first- degree relatives.
More than a quarter of depressed older persons is physically frail. Understanding the associations between frailty and depression may help to improve treatment outcome for late-life depression. The aim of this study is to test whether physical frailty predicts the course of late-life depression.
A cohort study (N=285) of depressed older persons aged ≥60 years with two years follow-up. Depression was classified according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria at baseline and at two-year follow-up. Severity of depression was assessed with the sum score as well as subscale scores of the Inventory of Depressive Symptomatology (IDS) at six-month intervals. Physical frailty was defined as ≥3 out of 5 criteria (handgrip strength, weight loss, poor endurance, walking speed, low physical activity).
Frail patients were more severely depressed compared to their non-frail counterparts. Multivariable logistic regression showed that physical frailty at baseline was associated with depression at two years follow-up, adjusted for socio-demographics and lifestyle factors. Linear mixed models showed that improvement of mood symptoms over time was independent of frailty status, whereas frailty had a negative impact on the course of the somatic and motivational symptoms of depression.
The negative impact of physical frailty on the course of depression may point to the potential importance of incorporating multi-facetted interventions in the treatment of late-life depression. Further understanding of the mediating mechanisms underlying the association between frailty and depression may further guide the development of these interventions.
When the heart is in danger – as is true during a myocardial infarction (MI) – this is life-threatening and as such can provoke specific fear: so-called cardiac anxiety. Both general anxiety and depression are associated with cardiac prognosis in MI-patients. However, as most treatment studies have not shown beneficial effects on cardiac prognosis, the need to examine specific aspects of anxiety and depression post-MI has been advocated.
We examined whether cardiac anxiety can be reliably assessed with the Cardiac Anxiety Questionnaire (CAQ) in 237 hospitalized MI-patients. Cross-sectional associations were explored, as well as possible trajectories of cardiac anxiety in the year post-MI (by latent class-analysis) and its association with quality of life. Finally, the prognostic association of cardiac anxiety with major adverse cardiac events (MACE) including all-cause mortality was examined with cox-regression-survival analysis.
The CAQ is a valid and reliable instrument in MI-patients and assessed fear, attention, avoidance of physical exercise, and safety-seeking behavior. Higher cardiac anxiety was associated with more psychological distress but lower severity in cardiac injury. In the year post-MI four cardiac anxiety trajectories were identified; higher cardiac anxiety was associated with worse quality of life. CAQ score significantly predicted MACE in a five-year-follow-up period, even after adjustment for age, cardiac disease severity and depressive symptoms (HRbaseline: 1.60 [95% CI: 1.05–2.45], P = 0.029; HR3-months: 1.71 [0.99–2.59]; P = 0.054).
Cardiac anxiety is an important and potentially modifiable factor in the treatment of MI-patients: it is prevalent and associated with quality of life and cardiac prognosis.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Many older adults with depressive disorder manifest anxious distress. This longitudinal study examines the predictive value of worry as a maladaptive cognitive emotion regulation strategy, and resources necessary for successful emotion regulation (i.e., cognitive control and resting heart rate variability [HRV]) for the course of anxiety symptoms in depressed older adults. Moreover, it examines whether these emotion regulation variables moderate the impact of negative life events on severity of anxiety symptoms.
Data of 378 depressed older adults (CIDI) between 60 and 93 years (of whom 144 [41%] had a comorbid anxiety disorder) from the Netherlands Study of Depression in Older Adults (NESDO) were used. Latent Growth Mixture Modeling was used to identify different course trajectories of six-months BAI scores. Univariable and multivariable longitudinal associations of worry, cognitive control and HRV with symptom course trajectories were assessed.
We identified a course trajectory with low and improving symptoms (57.9%), a course trajectory with moderate and persistent symptoms (33.5%), and a course trajectory with severe and persistent anxiety symptoms (8.6%). Higher levels of worry and lower levels of cognitive control predicted persistent and severe levels of anxiety symptoms independent of presence of anxiety disorder. However, worry, cognitive control and HRV did not moderate the impact of negative life events on anxiety severity.
Worry may be an important and malleable risk factor for persistence of anxiety symptoms in depressed older adults. Given the high prevalence of anxious depression in older adults, modifying worry may constitute a viable venue for alleviating anxiety levels.
Physical frailty and depressive symptoms are reciprocally related in community-based studies, but its prognostic impact on depressive disorder remains unknown.
A cohort of 378 older persons (≥ 60 years) suffering from a depressive disorder (DSM-IV criteria) was reassessed at two-year follow-up. Depressive symptom severity was assessed every six months with the Inventory of Depressive Symptomatology, including a mood, motivational, and somatic subscale. Frailty was assessed according to the physical frailty phenotype at the baseline examination.
For each additional frailty component, the odds of non-remission was 1.24 [95% CI = 1.01–1.52] (P = 040). Linear mixed models showed that only improvement of the motivational (P < 001) subscale and the somatic subscale (P = 003) of the IDS over time were dependent on the frailty severity.
Physical frailty negatively impacts the course of late-life depression. Since only improvement of mood symptoms was independent of frailty severity, one may hypothesize that frailty and residual depression are easily mixed-up in psychiatric treatment.
The level of physical activity (PA) and the prevalence of depression both change across the lifespan. We examined whether the association between PA and depression is moderated by age. As sense of mastery and functional limitations have been previously associated with low PA and depression in older adults, we also examined whether these are determinants of the differential effect of age on PA and depression.
1079 patients with major depressive disorder (aged 18–88 years) were followed-up after two-years; depression diagnosis and severity as well as PA were re-assessed. Linear and logistic regression analyses were used to test reciprocal prospective associations between PA and depression outcomes. In all models the interaction with age was tested.
PA at baseline predicted remission of depressive disorder at follow-up (OR = 1.43 [95% CI: 1.07–1.93], p =.018). This effect was not moderated by age. PA predicted improvement of depression symptom severity in younger (B = −2.03; SE =.88; p =.022), but not in older adults (B = 2.24; SE = 1.48; p =.128) (p =.015 for the interaction PA by age in the whole sample). The level of PA was relatively stable over time. Depression, sense of mastery and functional limitation were for all ages not associated with PA at follow-up.
Age did not moderate the impact of PA on depressive disorder remission. Only in younger adults, sufficient PA independently predicts improvement of depressive symptom severity after two-year follow-up. Level of PA rarely changed over time, and none of the determinants tested predicted change in PA, independent of age.
Comorbid anxiety disorders are common in late-life depression and negatively
impact treatment outcome. This study aimed to examine personality
characteristics as well as early and recent life-events as possible
determinants of comorbid anxiety disorders in late-life depression, taking
previously examined determinants into account.
Using the Composite International Diagnostic Interview (CIDI 2.0), we
established comorbid anxiety disorders (social phobia (SP), panic disorder
(PD), generalized anxiety disorder (GAD), and agoraphobia (AGO)) in 350
patients (aged ≥60 years) suffering from a major depressive
disorder according to DSM-IV-TR criteria within the past six months.
Adjusted for age, sex, and level of education, we first examined previously
identified determinants of anxious depression: depression severity,
suicidality, partner status, loneliness, chronic diseases, and gait speed in
multiple logistic regression models. Subsequently, associations were
explored with the big five personality characteristics as well as early and
recent life-events. First, multiple logistic regression analyses were
conducted with the presence of any anxiety disorder (yes/no) as dependent
variable, where after analyses were repeated for each anxiety disorder,
In our sample, the prevalence rate of comorbid anxiety disorders in late-life
depression was 38.6%. Determinants of comorbid anxiety disorders were a
lower age, female sex, less education, higher depression severity, early
traumatization, neuroticism, extraversion, and conscientiousness.
Nonetheless, determinants differed across the specific anxiety disorders and
lumping all anxiety disorder together masked some determinants (education,
Our findings stress the need to examine determinants of comorbid anxiety
disorder for specific anxiety disorders separately, enabling the development
of targeted interventions within subgroups of depressed patients.
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