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Anxiety in older adults often goes undiagnosed.
Anxiety disorder in the elderly is twice as common as dementia and four to six times more common than major depression. Anxiety is associated with poorer quality of life, significant distress and contributes to the onset of disability. Mortality risks are also increased, through physical causes, especially cardiovascular disease, and suicide. Diagnosing anxiety disorders in older adults remains a challenge because of the significant overlap in symptoms between physical disorders (shortness of breath; abdominal and chest pain; palpitations) and depression (disturbed sleep; poor attention, concentration and memory; restlessness). Good history taking is crucial in elucidating whether the complaint is of new onset or a recurrence of a previous disorder. The presence of comorbid depression should be clarified. If present, its temporal relationship with the anxiety symptoms will indicate whether there is an independent anxiety disorder. A medication review is warranted, as a number of drugs may be causative (calcium channel blockers, alpha- and beta-blockers, digoxin, L-thyroxine, bronchodilators, steroids, theophylline, antihistamines) or may cause anxiety in withdrawal (e.g. benzodiazepines). Substance and alcohol abuse should be excluded, as withdrawal from either may cause anxiety. A new or exacerbated physical illness may be related to anxiety. Medical investigations will help clarify the extent to which a particular somatic symptom is the result of anxiety.
Can exercise prevent cognitive decline?
As the tolerability of pharmacological agents decreases with age, exercise may be particularly helpful as a possible treatment or stabiliser of mood and cognitive function in older age. Exercise has been most commonly evaluated for the treatment of depression. Exercise interventions designed primarily for treatment of physical conditions in the elderly do appear to confer psychological benefits as well, with reduction in depressive symptoms over the course of treatment. The effects of exercise on reducing depressive symptoms are not dissimilar to the effects of antidepressant drugs and cognitive behaviour therapy. Exercise may be a useful low-tech intervention for people with mild to moderate depression. In particular, exercise may be helpful in the elderly and in patients who have had insufficient response to, or are intolerant of, pharmacotherapy. Mastery of a new skill and positive feedback from others may increase feelings of self-esteem and improve mood. Exercise may distract participants from persistent negative thoughts. Exercise has been shown to improve executive function acutely in adults of all ages. It is possible that dance routines or other exercise regimens requiring some cognitive input may confer additional benefit to cognitive function. Exercise has a moderate effect on the ability of people with dementia to perform activities of daily living and may improve cognitive function. Midlife exercise may also have an impact on later cognitive function.
2-Deoxyglucose autoradiography and repeated electroconvulsive shock in rats
Semiquantitative autoradiography with tritiated deoxyglucose was performed on rats after a series of 10 electro-convulsive shocks (ECS) administered over 10 days. The purpose of the study was to identify changes in cerebral glucose uptake after ECS. Glucose uptake over a large number of grey and white matter structures cannot be differentiated between rats receiving real and sham ECS. Various behavioral parameters measured in activity boxes do not show significant differences between the two groups.
European Psychiatric Association Guidance on psychotherapy in chronic depression across Europe.
PURPOSE: Patients with chronic depression (CD) by definition respond less well to standard forms of psychotherapy and are more likely to be high utilizers of psychiatric resources. Therefore, the aim of this guidance paper is to provide a comprehensive overview of current psychotherapy for CD. The evidence of efficacy is critically reviewed and recommendations for clinical applications and research are given. METHODS: We performed a systematic literature search to identify studies on psychotherapy in CD, evaluated the retrieved documents and developed evidence tables and recommendations through a consensus process among experts and stakeholders. RESULTS: We developed 5 recommendations which may help providers to select psychotherapeutic treatment options for this patient group. The EPA considers both psychotherapy and pharmacotherapy to be effective in CD and recommends both approaches. The best effect is achieved by combined treatment with psychotherapy and pharmacotherapy, which should therefore be the treatment of choice. The EPA recommends psychotherapy with an interpersonal focus (e.g. the Cognitive Behavioural Analysis System of Psychotherapy [CBASP]) for the treatment of CD and a personalized approach based on the patient's preferences. DISCUSSION: The DSM-5 nomenclature of persistent depressive disorder (PDD), which includes CD subtypes, has been an important step towards a more differentiated treatment and understanding of these complex affective disorders. Apart from dysthymia, ICD-10 still does not provide a separate entity for a chronic course of depression. The differences between patients with acute episodic depression and those with CD need to be considered in the planning of treatment. Specific psychotherapeutic treatment options are recommended for patients with CD. CONCLUSION: Patients with chronic forms of depression should be offered tailored psychotherapeutic treatments that address their specific needs and deficits. Combination treatment with psychotherapy and pharmacotherapy is the first-line treatment recommended for CD. More research is needed to develop more effective treatments for CD, especially in the longer term, and to identify which patients benefit from which treatment algorithm.
Sub-threshold depressive symptoms and brain structure: A magnetic resonance imaging study within the Whitehall II cohort.
BACKGROUND: Late-life sub-threshold depressive symptoms (i.e. depressive symptoms that do not meet the criteria for a diagnosis of major depressive disorder) are associated with impaired physical health and function, and increased risk of major depressive disorder. Magnetic resonance imaging (MRI) studies examining late-life major depressive disorder find structural brain changes in grey and white matter. However, the extent to which late-life sub-threshold depression is associated with similar hallmarks is not well established. METHODS: Participants with no history of major depressive disorder were selected from the Whitehall Imaging Sub-Study (n=358, mean age 69±5 years, 17% female). Depressive symptoms were measured using the Centre for Epidemiological Studies Depression Scale (CES-D) at three previous Whitehall II Study phases (2003-04, 2007-09 and 2012-13) and at the time of the MRI scan (2012-14). The relationships between current and cumulative depressive symptoms and MRI brain measures were explored using Voxel-Based Morphometry (VBM) for grey matter and Tract Based Spatial Statistics (TBSS) for white matter. RESULTS: Current sub-threshold depressive symptoms were associated with significant reductions in fractional anisotropy and increases in axial and radial diffusivity. There were no significant relationships between current depressive symptoms and grey matter measures, or cumulative depressive symptoms and MRI measures. LIMITATIONS: The prevalence (10%) of sub-threshold depressive symptoms means that analyses may be underpowered to detect subtle differences in brain structure. CONCLUSIONS: Current sub-threshold depressive symptoms are associated with changes in white matter microstructure, indicating that even mild depressive symptoms are associated with similar MRI hallmarks to those in major depressive disorder.
Metabolic Syndrome and Symptom Resolution in Depression: A 5-Year Follow-Up of Older Adults.
OBJECTIVE: Although metabolic syndrome is associated with the incidence of depression, little is known about its contribution to the course of depression. We examined whether metabolic syndrome and its components are associated with long-term symptom resolution in older adults with depressive symptoms. METHODS: Data from 965 participants in the Whitehall II cohort study (mean age = 62 years at baseline) were used to generate 1,172 person-observations of metabolic syndrome and its components (abdominal obesity, low level of high-density lipoprotein [HDL] cholesterol, high level of triglycerides, hypertension, and elevated fasting glucose or diabetes). All participants were depression cases at the beginning of 2 consecutive follow-up cycles: from 2002-2004 to 2007-2009 and from 2007-2009 to 2012-2013 (mean follow-up = 4.6 years). Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression scale caseness at the beginning and the end of the 2 cycles. RESULTS: In multivariable adjusted analyses, metabolic syndrome per se was not associated with symptom resolution. Of its components, low HDL cholesterol (risk ratio [RR] = 0.82; 95% CI, 0.68-1.00; P = .045) and high triglyceride levels (RR = 0.81; 95% CI, 0.70-0.95; P = .007) were associated with a lower likelihood of symptom resolution. These findings were replicated in a subpopulation without coronary heart disease and stroke (RR = 0.77 [95% CI, 0.63-0.95; P = .015] for low HDL cholesterol; RR = 0.79 [95% CI, 0.67-0.94; P = .006] for high triglycerides). CONCLUSIONS: Low HDL cholesterol and high triglyceride levels are associated with lower likelihood of long-term symptom resolution in depression. These data suggest that an adverse lipid profile, but not other components of metabolic syndrome, may delay recovery from depression.
A systematic review and meta-analysis of cross-sectional studies examining the relationship between mobility and cognition in healthy older adults.
Ageing is associated with declines in cognitive function and mobility. The extent to which this relationship encompasses the subdomains of cognition and mobility remains unclear, however. We searched MEDLINE and EMBASE databases for cross-sectional studies examining the association between objective mobility measures (gait, lower-extremity function, balance) and cognitive function (global, executive function, memory, processing speed) in healthy older adults. Of the 642 studies identified, 26 studies met the inclusion criteria, with a total of 26,355 participants. For each feature of physical mobility, the relation to each aspect of cognition was reviewed. In the context of each association, we summarised the results to date and performed random-effects meta-analyses of published data. Reviewed findings suggest that individuals with better mobility perform better on assessments of global cognition, executive function, memory and processing speed. Not all measures of mobility were equally associated with cognitive function, however. Although there was a larger number of gait and lower-extremity function studies, and this may have driven findings, most studies examining balance and cognition measures reported no significant results. Meta-analyses on reported associations supported results by revealing significant, albeit small, effect sizes in favour of a positive association between performance on mobility measures and cognitive assessments. Future research should aim to establish the mechanisms driving this relationship, as this may identify predictors of age-related impairments.
METACOHORTS for the study of vascular disease and its contribution to cognitive decline and neurodegeneration: An initiative of the Joint Programme for Neurodegenerative Disease Research.
Dementia is a global problem and major target for health care providers. Although up to 45% of cases are primarily or partly due to cerebrovascular disease, little is known of these mechanisms or treatments because most dementia research still focuses on pure Alzheimer's disease. An improved understanding of the vascular contributions to neurodegeneration and dementia, particularly by small vessel disease, is hampered by imprecise data, including the incidence and prevalence of symptomatic and clinically "silent" cerebrovascular disease, long-term outcomes (cognitive, stroke, or functional), and risk factors. New large collaborative studies with long follow-up are expensive and time consuming, yet substantial data to advance the field are available. In an initiative funded by the Joint Programme for Neurodegenerative Disease Research, 55 international experts surveyed and assessed available data, starting with European cohorts, to promote data sharing to advance understanding of how vascular disease affects brain structure and function, optimize methods for cerebrovascular disease in neurodegeneration research, and focus future research on gaps in knowledge. Here, we summarize the results and recommendations from this initiative. We identified data from over 90 studies, including over 660,000 participants, many being additional to neurodegeneration data initiatives. The enthusiastic response means that cohorts from North America, Australasia, and the Asia Pacific Region are included, creating a truly global, collaborative, data sharing platform, linked to major national dementia initiatives. Furthermore, the revised World Health Organization International Classification of Diseases version 11 should facilitate recognition of vascular-related brain damage by creating one category for all cerebrovascular disease presentations and thus accelerate identification of targets for dementia prevention.
The validity of the national adult reading test in estimating premorbid intellectual ability in long‐term survivors of hemispheric glioma and whole brain irradiation—a pilot study
We have examined the validity of using the National Adult Reading Test (NART) to estimate premorbid intellectual levels in long‐term survivors of glioma who had received whole brain prophylactic irradiation. Sixteen controls matched for age, sex, education and social class were compared with 16 patients. Patients made significantly more errors in the NART than controls, even after controlling for demographic variables. NART errors were compared with demographically predicted NART errors and NART‐predicted Wechsler Adult Intelligence Scale‐Revised (WAIS‐R) with pro‐rated WAIS‐R scores. While predicted and measured error scores were similar for the controls, for patients NART errors were higher than those predicted by demographic variables, while NART‐predicted WAIS‐R scores were higher than pro‐rated WAIS‐R. NART performance, therefore, appears to be detrimentally affected by brain changes due to the primary tumour or received treatment. This conclusion was supported by the finding that, in patients, NART errors were correlated with current IQ, but not with IQ predicted by socio‐demographic variables. After excluding four demented patients, this pattern of results was largely preserved. After excluding four patients with left temporal lobe involvement, the correlation of NART errors with current IQ disappeared, whereas that with NART errors predicted by socio‐demographic variables became significant. These results suggest that the NART can only be used with caution in survivors of malignant primary brain tumors, particularly if left temporal lobe structures are involved. Copyright © 1993 John Wiley & Sons, Ltd
Is 18F-FDG-PET suitable to predict clinical response to the treatment of geriatric depression? A systematic review of PET studies.
BACKGROUND: Geriatric depression is one of the most common psychiatric disorders in later life. It differs from earlier depression in its presentation, etiology, risk factors, protective factors and outcome. Positron emission tomography (PET) can be used to detect changes in neural circuitry in neuropsychiatric disorders, and several authors have assessed its role in the diagnosis and follow-up of patients with geriatric depression. We reviewed the current evidence on the use of fluorine-18-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) in geriatric depressed patients to find predictors of treatment response. METHODS: We searched PubMed/MEDLINE, Scopus, Embase, Cochrane Library, CINAHL and the PsycINFO databases to find relevant peer-reviewed articles on PET in geriatric depression using the search terms ('PET' or 'positron emission tomography') and ('mood' or 'affective disorder' or 'affective disorders' or 'depression' or 'dysthymia' or 'seasonal affective disorder'). RESULTS: Eleven articles comprising 128 patients were included. We extracted data on glucose uptake of depressed patients and controls at baseline and after different types of intervention (total sleep deprivation followed by a recovery sleep and treatment with selective serotonin reuptake inhibitors). CONCLUSIONS: 18F-FDG-PET showed significant alterations of glucose uptake in several brain areas, in particular the anterior cingulate cortex, which showed reduced metabolism after treatment, and was a predictor of treatment response.
Driving and dementia: a clinical update for mental health professionals.
Most people with mild dementia can continue to drive, but dementia is progressive and many patients and clinicians will be faced with questions about driving safety in the course of their illness. Determining when this happens is a complex decision, with risks of personal and public safety needing to be weighed against individual patient benefits of driving in terms of autonomy, independence and well-being. Decisions need to make reference to cognitive abilities, as well as other factors including physical comorbidity, vision, mobility, insight and history of driving errors and accidents. Deciding to stop driving, or being required to stop driving is often difficult for patients to accept and can be a particularly problematic consequence of a dementia diagnosis. Legal frameworks help in decision-making but may not provide sufficient detail to advise individual patients. We review the current guidelines and evidence relating to driving and dementia to help clinicians answer questions about driving safety and to consider the full range of assessment tools available.
Diagnosing early cognitive decline-When, how and for whom?
Mild cognitive impairment (MCI) is a term used to describe cognitive impairment in one or more cognitive domains that is greater than any expected age-related changes, but not of the magnitude to warrant a diagnosis of dementia. This review considers how early cognitive decline is diagnosed, focusing on the use of neuropsychological tests and neuroimaging, as well as the differential diagnosis. Potential treatments, including secondary prevention, post-diagnostic support and self-help are discussed. Finally, medico-legal matters such as driving, lasting power of attorney and employment are outlined.
What can gait tell us about dementia? Review of epidemiological and neuropsychological evidence.
BACKGROUND: Cognitive impairment and gait disorders in people over the age of 65 represent major public health issues because of their high frequency, their link to poor outcomes and high costs. Research has demonstrated that these two geriatric syndromes are closely related. METHODS AND RESULTS: We aim to review the evidence supporting the relationship between gait and cognitive impairment, particularly focusing on epidemiological and neuropsychological studies in patients with Mild cognitive impairment, Alzheimer's disease and Vascular dementia. The review demonstrates that gait and cognition are closely related, but our knowledge of their interrelationship is limited. Emerging evidence shows that gait analysis has the potential to contribute to diagnosis and prognosis of cognitive impairment. CONCLUSIONS: An integrated approach for evaluating these major geriatric syndromes, based on their close relationship, will not only increase our understanding of cognitive-motor interactions, but most importantly may be used to aid early diagnosis, prognosis and the development of new interventions.
Color perception differentiates Alzheimer's Disease (AD) from Vascular Dementia (VaD) patients.
BACKGROUND: Alzheimer's Disease (AD) and Vascular Dementia (VaD) are the most common causes of dementia in older people. Both diseases appear to have similar clinical symptoms, such as deficits in attention and executive function, but specific cognitive domains are affected. Current cohort studies have shown a close relationship between αβ deposits and age-related macular degeneration (Johnson et al., 2002; Ratnayaka et al., 2015). Additionally, a close link between the thinning of the retinal nerve fiber (RNFL) and AD patients has been described, while it has been proposed that AD patients suffer from a non-specific type of color blindness (Pache et al., 2003). METHODS: Our study included 103 individuals divided into three groups: A healthy control group (n = 35), AD (n = 32) according to DSM-IV-TR, NINCDS-ADRDA criteria, and VaD (n = 36) based on ΝΙΝDS-AIREN, as well as Magnetic Resonance Imaging (MRI) results. The severity of patient's cognitive impairment, was measured with the Mini-Mental State Examination (MMSE) and was classified according to the Reisberg global deterioration scale (GDS). Visual perception was examined using the Ishihara plates: "Ishihara Color Vision Test - 38 Plate." RESULTS: The three groups were not statistically different for demographic data (age, gender, and education). The Ishihara color blindness test has a sensitivity of 80.6% and a specificity of 87.5% to discriminate AD and VaD patients when an optimal (32.5) cut-off value of performance is used. CONCLUSIONS: Ishihara Color Vision Test - 38 Plate is a promising potential method as an easy and not time-consuming screening test for the differential diagnosis of dementia between AD and VaD.
Trajectories of Depressive Symptoms Before Diagnosis of Dementia: A 28-Year Follow-up Study.
IMPORTANCE: Neuropsychiatric symptoms, depressive symptoms in particular, are common in patients with dementia but whether depressive symptoms in adulthood increases the risk for dementia remains the subject of debate. OBJECTIVE: To characterize the trajectory of depressive symptoms over 28 years prior to dementia diagnosis to determine whether depressive symptoms carry risk for dementia. DESIGN, SETTING, AND PARTICIPANTS: Up to 10 308 persons, aged 35 to 55 years, were recruited to the Whitehall II cohort study in 1985, with the end of follow-up in 2015. Data analysis for this study in a UK general community was conducted from October to December 2016. EXPOSURES: Depressive symptoms assessed on 9 occasions between 1985 and 2012 using the General Health Questionnaire. MAIN OUTCOMES AND MEASURES: Incidence of dementia (n = 322) between 1985 and 2015. RESULTS: Of the 10 189 persons included in the study, 6838 were men (67%) and 3351 were women (33%). Those reporting depressive symptoms in 1985 (mean follow-up, 27 years) did not have significantly increased risk for dementia (hazard ratio [HR], 1.21; 95% CI, 0.95-1.54) in Cox regression adjusted for sociodemographic covariates, health behaviors, and chronic conditions. However, those with depressive symptoms in 2003 (mean follow-up, 11 years) had an increased risk (HR, 1.72; 95% CI, 1.21-2.44). Those with chronic/recurring depressive symptoms (≥2 of 3 occasions) in the early study phase (mean follow-up, 22 years) did not have excess risk (HR, 1.02; 95% CI, 0.72-1.44) but those with chronic/recurring symptoms in the late phase (mean follow-up, 11 years) did have higher risk for dementia (HR, 1.67; 95% CI, 1.11-2.49). Analysis of retrospective depressive trajectories over 28 years, using mixed models and a backward time scale, shows that in those with dementia, differences in depressive symptoms compared with those without dementia became apparent 11 years (difference, 0.61; 95% CI, 0.09-1.13; P = .02) before dementia diagnosis and became more than 9 times larger at the year of diagnosis (difference, 5.81; 95% CI, 4.81-6.81; P