MEDLINE Abstracts on Dementia and Depression

Search by, Ivan Goldberg, M.D.

Int J Geriatr Psychiatry 2001 Feb;16(2):139-146 Relationship between aggressive behaviors and depression among nursing home residents with dementia.
Menon AS, Gruber-Baldini AL, Hebel JR, Kaup B, Loreck D, Itkin Zimmerman S, Burton L, German P, Magaziner J.
Mental Health Clinical Center, Veterans Affairs Maryland Health Care Center, MD, USA..
BACKGROUND: Verbal and physical aggression are common behavior problems among nursing home residents with dementia. Depression among nursing home residents is also a common but underdiagnosed disorder.METHOD: Data collected on 1101 residents with dementia, newly admitted to a sample of 59 nursing homes across Maryland, were analyzed to determine if there was a relationship between depression and physical and verbal aggression.RESULTS: Residents with dementia who manifested physical or verbal aggression had a higher prevalence of depression than those without such behaviors (p<0.05).CONCLUSIONS: Our findings suggest that nursing home residents with aggressive behaviors should be screened for depression and treated..

Can J Neurol Sci 2001 Feb;28 Suppl 1:S83-95
Depressive syndromes in dementia.
Thorpe L, Groulx B
Department of Psychiatry, University of Saskatchewan, Saskatoon, Canada.
BACKGROUND: Depressive syndromes in dementia are common, treatment is challenging and controlled intervention studies are small in number. The goal of this paper is to review known information about the etiology, epidemiology and treatment of these syndromes, as summarized at the recent Canadian Consensus Conference on Dementia. METHODS: A number of Medline searches were performed (most recently updated in October 2000) using the subject categories dementia and depression, or apathy or emotional lability and other relevant articles were also reviewed. The background article was edited and amended at the Consensus Conference on Dementia. Final recommendations appearing in the summary article by Patterson et al were accepted by the group consensus process. Clinical discussion and informational updates were added for the current text by the authors. RESULTS: Depressive syndromes, ranging in severity from isolated symptoms to full depressive disorders, increase in dementia. While clear-cut depressive disorder is increased in this population, sub-syndromal disorders are even more common and cause considerable distress. Antidepressant treatment may improve the quality of life in depressed, demented people, although it is less successful than in those without cognitive impairment and carries more risk of iatrogenic effects. CONCLUSIONS: Physicians should be alert to the presence of depressive syndromes in dementia. Depressive illness should be treated and, when necessary, referral should be made to an appropriate specialist. Treatment must minimize iatrogenic effects. Although there is some support for treatment of syndromes that do not meet criteria for depressive disorder or dysthymia, the first line of intervention in these situations should involve nonpharmacological approaches.

Arch Gen Psychiatry 2001 Feb;58(2):190-196
A Family Study of Alzheimer Disease and Early- and Late-Onset Depression in Elderly Patients.
Heun R, Papassotiropoulos A, Jessen F, Maier W, Breitner JC
Department of Psychiatry, University of Bonn, Venusberg, D-53105 Bonn, Germany. heun@uni-bonn.de
BACKGROUND: The substantial symptomatic overlap between depression and dementia in old age may be explained by common genetic vulnerability factors. METHODS: We investigated this idea by comparing the occurrence of both disorders in first-degree relatives of 78 patients with Alzheimer disease (AD), of 74 with late-onset depression (onset age of >/=60 years), of 78 with early-onset depression, of 53 with comorbid lifetime diagnoses of AD/depression, and of 162 population control subjects. Diagnostic information on their 3002 relatives was obtained from structured direct assessments and from family history interviews. RESULTS: The 90-year lifetime incidence of primary progressive dementia was significantly higher in relatives of patients with AD (30%) and comorbid AD/depression (27%) than in relatives of patients with early-onset (21%) or late-onset (26%) depression, or of controls (22%) (P =.01). Lifetime incidence of depression was significantly higher in relatives of patients with early-onset depression (13%) than in relatives of patients with AD (10%) or controls (9.0%) (P =.006). Lifetime incidence of depression was similar in control relatives and in relatives of those patients with comorbid AD/depression (8.6%). Relatives of patients with late-onset depression also showed similar occurrence of depression until the age of 80 years, but the figure increased sharply thereafter to 19.1% by the age of 90 years. CONCLUSIONS: Primary progressive dementia and early-onset depression represent clinical entities with distinct inheritance. Late-onset depression does not share substantial inheritance in common with dementia or with early-onset depression, but does show modest familial clustering.

Biol Psychiatry 2001 Jan 15;49(2):130-136
Cognitive impairment in depression is not associated with neuropathologic evidence of increased vascular or Alzheimer-type pathology.
O'Brien J, Thomas A, Ballard C, Brown A, Ferrier N, Jaros E, Perry R
Institute for the Health of the Elderly, University of Newcastle upon Tyne, (JO, AT, CB, AB, EJ, RP), Newcastle upon Tyne, UK
Background: Cognitive impairment is common in depression, but underlying mechanisms remain unknown. We examined whether increases in Alzheimer-type or vascular pathology are associated with cognitive impairments in elderly depressed subjects.Methods: Eleven subjects who had died during a well-documented episode of DSM-IV major depression were included. Neuropathologic assessments, blind to group membership, included standardized assessment of neuritic plaques, neurofibrillary tangles, and Lewy Bodies in frontal, temporal, parietal, and occipital cortices. Braak staging of Alzheimer pathology was also performed. Cerebral microvascular disease was scored according to a previously validated scale, and a score for cerebral and systemic atheroma of large and medium sized arteries was obtained.Results: No subject had Lewy bodies. Plaque and tangle counts for all subjects were well within published norms for age-matched control subjects. There were no significant differences in plaque or tangle counts between subjects who were cognitively impaired (n = 5) and those who were nonimpaired (n = 6) during their depressive illness. Similarly, neither total microvascular pathology nor deep frontal microvascular pathology differed between the two groups.Conclusions: Our results indicate that the liability for some patients to develop cognitive impairment during a depressive episode is not related to an increase in Alzheimer-type or vascular neuropathologic change. This indicates that other mechanisms must underlie both the cognitive impairment associated with depression and the observation that depression is a risk factor for dementia.

Am J Psychiatry 2001 Jan;158(1):68-72
The specificity of depressive symptoms in patients with Alzheimer's disease.
Chemerinski E, Petracca G, Sabe L, Kremer J, Starkstein SE
Department of Neuropsychiatry, Raul Carrea Institute of Neurological Research, Buenos Aires, Argentina.
OBJECTIVE: This study assessed the specificity of depressive symptoms in patients with Alzheimer's disease and examined the discrepancies between patient and caregiver symptom reports. METHOD: The study group was composed of a series of 233 patients with Alzheimer's disease, 47 patients with depression but without dementia, and 20 healthy comparison subjects; the latter two groups were comparable in age with the patients with Alzheimer's disease. The patients and comparison subjects received a comprehensive psychiatric evaluation, which included administration of the Hamilton Depression Rating Scale and the Structured Clinical Interview for DSM-IV. RESULTS: Patients with Alzheimer's disease with a score of 2 or higher on the "depressed mood" item of the Hamilton depression scale, as scored by their respective caregivers, comprised a group with depressed mood (N=92), whereas patients who scored 0 on this item comprised a group without depressed mood (N=62). A statistical comparison of the scores on the remaining Hamilton depression scale items (2-16) between the Alzheimer's disease patients with and without depressed mood revealed significant differences on all items, except "loss of appetite." However, there were no significant differences on any single Hamilton depression scale item between the Alzheimer's disease patients without depressed mood and the age-comparable healthy comparison subjects. CONCLUSIONS: Depressive symptoms are not widespread among patients with Alzheimer's disease but are significantly related to an underlying depressed mood. Patients with Alzheimer's disease may not be fully aware of the extent of their depressive symptoms.

Curr Psychiatry Rep 2000 Oct;2(5):427-433
Depression in Alzheimer's Disease and Other Dementias.
Boland RJ
Center for Behavioral and Preventive Medicine, Miriam Hospital/LifeSpan, 164 Summit Avenue, Providence, RI 02906, USA. Robert_Boland_1@Brown.edu
Much of our current knowledge about depression in Alzheimer's disease and other dementias is based on the 1991 National Instiute of Health Consensus Development Panel on the Diagnosis and Treatment of Depression in Late Life, and its subsequent 1997 update. However, much research has taken place since these reports. This article summarizes this research, particularly research that has taken place in the past year. Comorbid depression is common in all types of dementia. It may, however, appear to be different from classic depression. Unlike classic depression, the depression found in dementia may result from anatomic damage to the brain. This is most clearly demonstrated in vascular depression. The implications of this are many. Treatments for depression are designed for classic depression. For those with vascular depression (and other depressions associated with dementia) treatments may not be as efficacious. Newer strategies, including agents not commonly thought of as antidepressants, may be needed.

Am J Psychiatry 2000 Dec;157(12):1949-54
Changes in cognitive functioning following treatment of late-life depression.
Butters MA, Becker JT, Nebes RD, Zmuda MD, Mulsant BH, Pollock BG, Reynolds CF
Department of Psychiatry, Western Psychiatric Institute and Clinic, Pittsburgh, PA 15213, USA.
OBJECTIVE: Knowledge of the relationship between various clinical characteristics and cognitive functioning is advancing, but little is known about the cognitive response to treatment for geriatric depression. The purpose of this study was to examine the cognitive response to treatment for patients with late-life depression. METHOD: Subjects included 45 nondemented, elderly depressed patients who achieved remission after 12 weeks of antidepressant treatment and 20 elderly comparison subjects. All subjects were administered a battery of clinical measures, including cognitive screening instruments, before and after treatment. RESULTS: As a group, the elderly depressed patients showed a small improvement in overall cognitive functioning after treatment. Among depressed patients with concomitant cognitive impairment at baseline, performance on the Mattis Dementia Rating Scale domains of conceptualization and initiation/perseveration improved significantly relative to those of depressed patients with normal cognition. Despite the improvement following treatment, the overall level of cognitive functioning in the elderly depressed patients with cognitive impairment at baseline remained mildly impaired, especially in the memory and initiation/perseveration domains. CONCLUSIONS: Elderly depressed patients with cognitive impairment may experience improvement in specific domains following antidepressant treatment but may not necessarily reach normal levels of performance, particularly in memory and executive functions. This subgroup of late-life depression patients is likely at high risk of developing progressive dementia.

J Am Geriatr Soc 2000 Sep;48(9):1092-7
Depressive symptoms and risk of Alzheimer's disease in more highly educated older people.
Geerlings MI, Schmand B, Braam AW, Jonker C, Bouter LM, van Tilburg W
Institute for Research in Extramural Medicine (EMGO Institute), Vrije Universiteit, Amsterdam, The Netherlands.
BACKGROUND AND OBJECTIVE: In an earlier study we observed that a depressive syndrome was highly predictive of developing Alzheimer's disease (AD) in older persons with normal baseline cognition and higher levels of education. We interpreted these findings as the depression being an early noncognitive manifestation of AD in persons with more cognitive reserve. The present study examines whether specific symptoms of depression can be identified that predict AD among older subjects with higher levels of education. DESIGN AND PARTICIPANTS: In the community-based Amsterdam Study of the Elderly (AMSTEL), a sample of 3,147 nondemented persons with normal cognition, 65 to 84 years old, was selected and divided into subjects with >8 years and < or =8 years of education. At baseline, the presence or absence of 12 specific symptoms of depression was assessed. At follow-up, patients with incident AD were diagnosed according to DSM-IV criteria in a two-step diagnostic procedure. RESULTS: After an average follow-up of 3.2 years, 1,911 persons were reevaluated, of whom 22 with > 8 years and 31 with < or =8 years of education had developed AD. Multivariate logistic regression analyses showed that among persons with >8 years of education depressed mood and subjective bradyphrenia were strongly associated with incident AD. No association between depressive symptoms and AD was observed among subjects with < or =8 years of education. CONCLUSIONS: Both depressed mood and subjective bradyphrenia seem to indicate subclinical AD in older people with higher levels of education. Clinicians should be alert that in these persons, AD may become apparent within a relatively short period of time.

Br J Psychiatry 2000 Jun;176:568-75
Depression and risk of cognitive decline and Alzheimer's disease. Results of two prospective community-based studies in The Netherlands.
Geerlings MI, Schoevers RA, Beekman AT, Jonker C, Deeg DJ, Schmand B, Ader HJ, Bouter LM, Van Tilburg W
Institute for Research in Extramural Medicine, Vrije Universiteit, Amsterdam, The Netherlands. geerlings@epib.fgg.eur.nl
BACKGROUND: Depression may be associated with cognitive decline in elderly people with impaired cognition. AIMS: To investigate whether depressed elderly people with normal cognition are at increased risk of cognitive decline and Alzheimer's disease. METHODS: Two independent samples of older people with normal cognition were selected from the community-based Amsterdam Study of the Elderly (AMSTEL) and the Longitudinal Aging Study Amsterdam (LASA). In AMSTEL, depression was assessed by means of the Geriatric Mental State Schedule. Clinical diagnoses of incident Alzheimer's disease were made using a two-step procedure. In LASA, depression was assessed with the Center for Epidemiologic Studies Depression Scale. Cognitive decline was defined as a drop of > or = 3 on the Mini-Mental State Examination at follow-up. RESULTS: Both in the AMSTEL and the LASA sample, depression was associated with an increased risk of Alzheimer's disease and cognitive decline, respectively, but only in subjects with higher levels of education. CONCLUSIONS: In a subgroup of more highly educated elderly people, depression may be an early manifestation of Alzheimer's disease before cognitive symptoms become apparent.

Int J Geriatr Psychiatry 2000 Aug;15(8):729-35
The benefits and risks of ECT for patients with primary dementia who also suffer from depression.
Rao V, Lyketsos CG
Neuropsychiatry and Memory Group, Department of Psychiatry and Behavioral Sciences, School of Medicine, The John Hopkins University, Baltimore, MD 21287, USA.
BACKGROUND: Major depression afflicts 20-25% of patients with dementia. Of these, about a third do not improve with antidepressant therapy and may be suitable candidates for electronconvulsive treatment (ECT). However, the use of ECT is dementia patients is concerning due to possible adverse effects on memory and cognition. Outcome studies of ECT in patients with primary dementia and depression are very rare. OBJECTIVE: To determine the effectiveness and complications of ECT treatment for depression in dementia. METHOD: A chart review was conducted of all 31 patients wit ha discharge diagnosis of 'Dementia with depression' treated with ECT at the Johns Hopkins Hospital, over a five-year period. Admission and discharge ratings were made on the Mini-Mental State Examination (MMSE) and the Montgomery-Asberg Depression Rating Scale (MADRS) as part of the clinical routine. RESULTS: All patients suffered from dementia: 55% had vascular dementia, 13% Alzheimer's disease, and 32% degenerative dementia of uncertain etiology. The admission MADRS mean score was 27.5 (SD 8.1) and the MMSE mean score was 18.8 (SD 5. 5). The patients received between 1 and 23 ECT treatments (mean 9, SD 5.7). At discharge, there was a statistically significant mean decline on the MADRS of 12.28 points (p<0.01). Forty percent had scores less than 10 (normal) on the MADRS. While 49% of patients developed delirium, by discharge there was also a significant mean increase (improvement) in MMSE of 1.62 points (p<0.02). CONCLUSIONS: ECT is an effective treatment for depression in dementia, leading to improvements in both mood and cognition. Multiple ECT treatments may be necessary before a significant improvement in mode is achieved.

AORN J 2000 Aug;72(2):209-17; quiz 218-21, 223, 225-6
Depression, delirium, and dementia in the elderly patient.
Martin JH, Haynes LC
University of Northern Colorado School of Nursing, Greeley, USA.
Perioperative nurses commonly care for patients with changes in mental status, especially elderly patients. Three common mental status disorders in the elderly are delirium, depression, and dementia. Each of the disorders can have similar clinical presentations. Despite similarities, the appropriate nursing interventions may vary significantly. Interventions discussed in this article focus on the etiology of the presenting problem and the nursing interventions that will promote the most positive outcome for the patient.

Clin Neuropsychol 1999 May;13(2):136-46
Neuropsychological characteristics of the dementia syndrome of depression: onset, resolution, and three-year follow-up.
McNeil JK
Atlantic Health Sciences Corporation, Saint John, New Brunswick, Canada.
In this prospective double-blind study 13 hospitalized older adults with dementia syndrome of depression (DSD) were compared to 14 with Alzheimer's dementia with a concurrent major depression on a battery of neuropsychological tests. On admission to hospital (onset), patients with DSD differed from those with Alzheimer's dementia and depression only in that the former had stronger short-term verbal memory. Resolution of depression in patients with DSD resulted in a return to normal levels in most measures of verbal functioning, but nonverbal abilities remained impaired. Three years later those with DSD continued to cognitively outperform those with Alzheimer's dementia, indicating that treating depression in DSD appears to "buy back" up to 3 years of above-baseline cognitive functioning.

J Clin Psychiatry 2000 Jul;61(7):487-92
Effects of donepezil on emotional/behavioral symptoms in Alzheimer's disease patients.
Weiner MF, Martin-Cook K, Foster BM, Saine K, Fontaine CS, Svetlik DA
Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas 75235-9070, USA.
BACKGROUND: This open-label study examined the effects of the reversible cholinesterase inhibitor donepezil on emotional/behavioral symptoms in Alzheimer's disease (AD) patients. METHOD: Patients were diagnosed as having probable/possible AD by National Institute of Neurological and Communicative Disorders and Stroke/Alzheimer's Disease and Related Disorders Association (NINCDS/ADRDA) criteria. This study used the CERAD Behavior Rating Scale for Dementia (CBRSD) and its subscales to evaluate a group of 25 AD patients treated with donepezil. Dosage was increased at 4 months for most patients from 5 to 10 mg q.h.s. Analysis of variance was used to compare scores over a period of 12 months. These patients were also compared, using t tests, to a reference group that had received no donepezil or other anticholinesterase. RESULTS: Donepezil administration was associated with improvement in Mini-Mental State Examination (MMSE) and CBRSD total scores at 3-month evaluation (p< or =.05). CBRSD depression and behavioral dysregulation scores improved transiently at 4 months (p< or =.05). MMSE, CBRSD total, CBRSD depression, and CBRSD behavioral dysregulation scores returned to baseline levels at 12 months, in contrast to the reference group, whose MMSE and CBRSD total scores worsened minimally over the 12 months. CONCLUSION: Donepezil has a mildly positive effect on emotional/behavioral symptoms in AD in addition to its effect on cognitive function.

J Geriatr Psychiatry Neurol 2000 Summer;13(2):72-7
Depressive syndromes and functional disability in dementia.
Hargrave R, Reed B, Mungas D
Department of Psychiatry, University of California, Davis, Oakland 94602, USA.
The goals of this study were to assess (1) the prevalence of major and minor depression in Alzheimer's disease (AD), ischemic vascular dementia (IVD), and mixed dementia (AD/IVD); (2) demographic and clinical variables that may be associated with depression; and (3) the relationship between depression severity and the level of functional impairment and cognitive decline. Demographic variables, depression diagnoses, Mini-Mental State Examination scores, and Blessed Roth Dementia Rating Scale scores were compared in patients with AD (N = 582), IVD (N = 48), and mixed dementia (N = 61) using analysis of variance and linear regression models. Data were collected using standardized rating instruments at the time of the patients' initial evaluations at the University dementia clinics. The results were that (1) depression was related to lower education, (2) major depression was more prevalent in IVD compared to probable AD, and (3) functional impairment was greater in patients with minor or major depression compared to patients without depression. Our data suggest that the level of functional disability in dementia may be related to severity of depression. Additional studies are needed to validate our results and examine the contribution of additional neurobiologic factors to the pathophysiology of depression in dementia.

J Geriatr Psychiatry Neurol 2000 Summer;13(2):65-71
Family history of dementia and current depression in nondemented community-dwelling older adults.
Harwood DG, Barker WW, Ownby RL, Mullan MJ, Duara R
Department of Psychiatry and Biobehavioral Sciences, Neuropsychiatric Institute and Hospital, University of California, Los Angeles School of Medicine, USA.
Since it has been postulated that mood disturbance in nondemented older adults may represent a prodromal feature of dementia for a subgroup of patients, it would be expected that patients with these symptoms would evidence a greater prevalence of family history of dementia. In a sample of 3225 community-dwelling cognitively intact elderly recruited from a free memory-screening program, we found that current depression was more common in participants with a positive versus a negative family history of dementia in first-degree relatives (17% versus 11%; Fisher's Exact Test, P < .0001). This relationship remained significant after controlling for age, education, gender, ethnicity, and Folstein Mini-Mental State Examination score (OR = 1.5; 95% CI = 1.2-1.9, Wald X2 = 15.5, P < .001). The results suggest that symptoms of depression may herald the onset of an incipient dementia syndrome in a subset of geriatric patients. Alternatively, the results may be indicative of familial aggregation of dementia and depression.

Gerontology 2000 Jul-Aug;46(4):219-27
Is depression a risk factor for dementia or cognitive decline? A review.
Jorm AF
NHMRC Psychiatric Epidemiology Research Centre, Australian National University, Canberra. Anthony.Jorm@anu.edu.au
BACKGROUND: It is generally accepted that depression can be associated with significant cognitive deficits and that depression can be comorbid with dementia. OBJECTIVE: This review seeks to go further and ask whether depression earlier in life can be a risk factor for subsequent dementia or for cognitive decline. METHODS: A review was made of the epidemiological evidence from case-control and prospective studies that depression is a risk factor. The literature was also reviewed in relation to six hypotheses that might explain an association: (1) depression treatments are a risk factor for dementia, (2) dementia and depression share common risk factors, (3) depression is a prodrome of dementia, (4) depression is an early reaction to cognitive decline, (5) depression affects the threshold for manifesting dementia, and (6) depression is a causal factor in dementia. RESULTS: A meta-analysis found that depression was associated with an increased risk of subsequent dementia in both case-control studies (95% CI for relative risk: 1.16-3.50) and prospective studies (95% CI: 1.08-3.20). There was little support for hypotheses 1 and 2. The other hypotheses have limited support, but warrant further research. CONCLUSION: There is sufficient evidence to take seriously the possibility that depression is a risk factor for dementia and cognitive decline. Further work is needed to examine depression as a prodrome of vascular dementia, depression as an early reaction to perceived cognitive decline, the effects of depression on the threshold for manifesting dementia, and depression as a source of hippocampal damage through a glucocorticoid cascade.

J Affect Disord 2000 Aug;59(2):97-106
Anxiety, depression and psychosis in vascular dementia: prevalence and associations.
Ballard C, Neill D, O'Brien J, McKeith IG, Ince P, Perry R
MRC Neurochemical Pathology Unit, Newcastle General Hospital, Westgate Road, NE4 6BE, Newcastle upon Tyne, UK.
BACKGROUND: Little is known about psychiatric symptoms in Vascular dementia (VaD). METHOD: 92 patients with VaD, and 92 patients with Alzheimer's disease (AD) are reported. The evaluation included standardised measures of mood and psychosis. RESULTS: 72% of VaD patients and 38% of those with AD had two or more anxiety symptoms. VaD patients with severe dementia (94%) were the most likely to be anxious. Depression was also significantly more common in VaD patients (19% vs. 8%) whereas psychotic symptoms were prevalent in both dementias. CONCLUSION: Psychiatric symptoms are common in VaD, especially in patients with moderate or severe dementia. Rigorous assessment of psychiatric symptoms in VaD should be part of good clinical practice.

Int J Geriatr Psychiatry 2000 May;15(5):419-33
Cerebrovascular disease and late life depression: an age old association revisited.
Rao R
Guy's Hospital, St Thomas' Street, London SE1 9RT, UK. rrao@globalnet.co.uk
OBJECTIVES: To examine the relationship between depression and cerebrovascular disease in three distinct settings: depression in established cerebrovascular disease, cerebrovascular disease in established depression and depression in vascular dementia. METHODS: Medline, EMBASE, PsychLit and PsychInfo databases were scanned to locate relevant articles. Data were also extracted from other articles, cited by those articles generated from the above databases. RESULTS: Using operational criteria, the prevalence of depression is higher than controls only within the first year after stroke, but most studies have not employed control groups. The prevalence of depression in vascular dementia compared with Alzheimer's disease is higher in the majority of studies, but matching for sociodemographic factors and severity of cognitive impairment has been inconsistent. An association between frontal/subcortical cerebrovascular lesions and depression in later life has been observed, but there may be methodological flaws underlying this observation in some computerized tomography studies. CONCLUSION: There is some evidence that cerebrovascular disease has an aetiopathological role in late life depression. The increased likelihood of damage to frontal/subcortical brain circuitry following stroke, transient ischaemia and hypertension may explain the high prevalence of depression in older people with vascular risk factors. More valid definitions of lesion location and the use of appropriately matched control groups would seek to clarify this issue. The extrapolation to care settings from the high prevalence of depression accompanying cerebrovascular disease and the prolongation of disability in depressed people with stroke, suggests closer liaison between old age psychiatrists, neurologists and physicians caring for the elderly.

Arch Gen Psychiatry 1999 Mar;56(3):261-6
The temporal relationship between depressive symptoms and dementia: a community-based prospective study.
Chen P, Ganguli M, Mulsant BH, DeKosky ST
Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA, USA.
BACKGROUND: The temporal relationship between the appearance of depressive symptoms and the clinical onset of dementia and Alzheimer disease was evaluated in a community sample. METHODS: An original sample of 1366 subjects aged 65 years or older, selected randomly from a rural Pennsylvania community, was cognitively screened at study entry and every 2 years thereafter. A subset of 954 survivors of this cohort without dementia was screened for depressive symptoms at the second and subsequent data-collection waves. A "depression cluster" was identified by the presence of 5 or more depressive symptoms, including depressed mood, at the time of screening. Cognitively impaired subjects and a sample of unimpaired controls underwent standardized clinical evaluation to determine the presence of incident dementia (by DSM-III-R criteria) and probable or possible Alzheimer disease (by criteria of the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association) and to estimate the clinical onset of dementia symptoms. RESULTS: A highly increased probability of the depression cluster developing existed among subjects following the onset of dementia (15.4% [6/39]) and Alzheimer disease (17.6% [6/34]) compared with subjects without dementia (3.2% [23/712]). The odds ratios, after adjustment for age, sex, education level, and self reported memory loss, for the development of depression were 6.5 (95% confidence interval, 2.2-19.1) in subjects with Alzheimer disease and 5.2 (95% confidence interval, 1.8-15.2) in subjects with overall dementia. Depressive symptoms did not confer a significantly increased relative risk of dementia (1.27; 95% confidence interval, 0.55-2.93) or Alzheimer disease (1.28; 95% confidence interval, 0.51-3.20). CONCLUSION: Depressive symptoms appeared to be early manifestations, rather than predictors, of Alzheimer disease in this community sample.

Psychol Med 1999 Jan;29(1):113-20
The impact of dementia on the detection of depression in elderly subjects from the general population.
Papassotiropoulos A, Heun R, Maier W
Department of Psychiatry, University of Bonn, Germany.
BACKGROUND: The performance of the CES-D in a sample of elderly community residents was assessed. The influence of dementia on test performance and the necessity for the use of four factor scores instead of a single summary score of the CES-D were studied. METHOD: Two hundred and eighty-seven subjects out of the general population aged 60-99 years were personally interviewed with standardized diagnostic tools and completed the CES-D. Best-estimate diagnoses served as 'gold standards' for receiver operating characteristics (ROC) analysis. RESULTS: The CES-D discriminated well between depressive and non-depressive subjects. Exclusion of demented subjects from the sample did not markedly increase test performance. Current depressive illness and dementia led to high scores on the CES-D. Unlike the factors 'depressive affect', 'somatic/vegetative complaints', and 'interpersonal relations', the factor' positive affect' of the CES-D discriminated well between demented and non-demented participants. CONCLUSIONS: The CES-D is a valid instrument for screening for depression in a community sample of elderly subjects. Its use can be recommended even if the presence of dementia is likely. The use of factor scores of the CES-D does not substantially contribute to an improvement of overall test performance, but, nevertheless, allows a more detailed insight and better interpretation of test results.

Dement Geriatr Cogn Disord 1999 Mar-Apr;10(2):64-9
Differential diagnosis of aging, dementia of the Alzheimer type and depression with EEG-segmentation.
Ihl R, Brinkmeyer J
Department of Psychiatry, University of Dusseldorf, Germany.
EEG segmentation can be used to measure altered brain function in aging and diseases of the brain. The parameter 'number of different segments' makes clear how many different potential fields are involved in brain activity during a given period of time. It should represent effects of aging and disease. To prove this assumption, 11 young and 10 aged controls, 12 patients with mild dementia of the Alzheimer type (DAT), 10 young and 12 aged patients with endogenous depression were included in the study. The number of different segments in the beta frequency band between 16 and 19.75 Hz was measured according to the theory of Lehmann et al. [Clinical Neurophysiology 1987;67:271-288], and the segments were classified by their location on the scalp. The Mann-Whitney U test was used for statistical comparison. Aged controls had more different segments than young controls (n = 21, U = 14, p < 0.0038). Patients with DAT had less different segments than healthy aged controls (n = 22, U = 18.5, p < 0.0061). Aged patients with endogenous depression had more different segments than patients with mild DAT (n = 24, U = 32, p < 0.021). The reduction of the number of different segments in DAT compared to controls and patients suffering from depression may be helpful for differential diagnosis. The higher number of different segments in aged versus young controls could be interpreted as a sign of increased complexity in the aged brain.

Am J Psychiatry 1999 Jan;156(1):66-71
Physical aggression in dementia patients and its relationship to depression.
Lyketsos CG, Steele C, Galik E, Rosenblatt A, Steinberg M, Warren A, Sheppard JM
Department of Psychiatry and Behavioral Sciences, School of Medicine, The Johns Hopkins University, Baltimore, MD, USA. kostas@jhmi.edu
OBJECTIVE: The goal of this study was to determine the frequency of physically aggressive behavior in community-residing patients with dementia and its relationship to depression. METHOD: A consecutive series of 541 patients with DSM-IV-defined dementia underwent comprehensive neuropsychiatric evaluation and were rated on the Cornell Scale for Depression in Dementia, the Mini-Mental State, the Psychogeriatric Dependency Rating Scale, and the General Medical Health Rating. RESULTS: Physically aggressive behavior was exhibited by 79 patients in the 2 weeks before evaluation. Aggressive behavior was closely associated with moderate to severe depression, male gender, and greater impairment in activities of daily living, even after adjustment for delusions, hallucinations, sleep disturbance, and severity of cognitive impairment. After adjustment for depression, gender, and impairment in activities of daily living, there was no association between physically aggressive behavior and the presence of either delusions or hallucinations. CONCLUSIONS: A substantial minority of patients with dementia exhibit physically aggressive behavior, and this aggression is strongly linked with the presence of depressive symptoms. It is possible that the identification and treatment of depression in dementia may be a means of preventing and managing physically aggressive behavior.

Arch Gen Psychiatry 1999 Jan;56(1):45-51
Lack of association between depression and loss of neurons in the locus coeruleus in Alzheimer disease.
Hoogendijk WJ, Sommer IE, Pool CW, Kamphorst W, Hofman MA, Eikelenboom P, Swaab DF
Netherlands Institute for Brain Research, Department of Psychiatry, Valerius Clinic, Amsterdam. witteh@pca-znw.nl
BACKGROUND: Depression, one of the most frequent psychiatric disturbances in Alzheimer disease (AD), is proposed to have its neurobiological basis in neuron loss in the noradrenergic locus coeruleus, although this is not the case in idiopathic depression. METHODS: We performed image analyzer-assisted morphometry of the locus coeruleus in 6 depressed, 6 transiently depressed, and 6 nondepressed patients with AD and in 8 control subjects, emphasizing longitudinal psychiatric evaluations and matching for the clinical and neuropathological severity of dementia. RESULTS: The mean (+/-SD) number of pigmented neurons in the locus coeruleus in controls (11 607+/-946) was higher than in patients with AD, regardless of being depressed (5165+/-928; P=.001), transiently depressed (5647+/-1163; P=.003), or nondepressed (3717+/-661; P=.001). No significant difference was found in the number of pigmented neurons between patients with AD who were depressed, transiently depressed, and nondepressed. Patients who had depression at the onset of AD had a higher pigmented neuron number than other patients with AD. CONCLUSIONS: We confirmed the loss of pigmented neurons in the locus coeruleus of patients with AD; however, no supplementary loss of pigmented neurons in the locus coeruleus was found in patients with depression and AD. This finding resembles the situation in idiopathic depression, but is in contrast with earlier studies on depression in AD.

Age Ageing 1998 Jul;27(4):503-7
Suicidal ideation and the 'wish to die' in dementia patients: the role of depression.
Draper B, MacCuspie-Moore C, Brodaty H
Academic Department of Psychogeriatrics, Prince Henry Hospital, University of New South Wales, Sydney, Australia. B.Draper@unsw.edu.au
OBJECTIVE: To determine the prevalence of self-reported suicidal ideation and the 'wish to die' in dementia patients, their association with depressive symptoms and the type of dementia. DESIGN: The cohort was formed retrospectively of consecutive referrals between 1985 and 1994 of cognitively impaired patients who met American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, third edition and third edition, revised, criteria for dementia. They were assessed for depression using the 21-item Hamilton Rating Scale for Depression (HRSD) which includes an item on suicide. SETTING: An outpatient multidisciplinary memory disorders clinic in Sydney, Australia. PATIENTS: The sample comprised 221 patients with dementia: 148 with Alzheimer's disease according to NINCDS-ADRDA criteria, 24 with vascular dementia diagnosed by a Hachinski ischaemia scale score of seven or more, plus focal neurological signs, symptoms or computed tomography-visible lesions, and 49 with other dementias. MEASURES: Cognitive impairment was measured by the Mini-Mental State Examination and the Blessed orientation-information-memory-concentration test and dementia scales, depression by the 21-item HRSD, suicidal ideation and the 'wish to die' as defined by the suicide item on the HRSD, functional capacity by the activities of daily living scale and the instrumental activities of daily living scale. Caregiver psychological morbidity was assessed with the General Health Questionnaire. RESULTS: 12 patients (5.4%) felt life was not worth living, seven (3.2%) 'wished to die' or had thoughts of death, two (0.9%) had suicidal ideation or gestures and none had made any suicide attempts. The nine patients who 'wished to die' or had suicidal ideation scored 12 or more on the HRSD. Of these, six were clinically depressed. Suicidal ideation and the 'wish to die' were significantly correlated with the presence of depressive symptoms as measured by the HRSD (suicide item excluded), but only in those with Alzheimer's disease. There were no significant differences in HRSD scores between the dementia groups. Suicidal ideation was unrelated to the presence of insight into loss of memory. CONCLUSIONS: Suicidal ideation and/or the 'wish to die' is self-reported in 4% of dementia patients attending a memory disorders clinic and is associated with comorbid depressive symptoms, particularly in Alzheimer's disease.

Arch Gen Psychiatry 1998 Dec;55(12):1082-3
The depression-dementia conundrum: integrating clinical and epidemiological perspectives.
Meyers BS, Bruce ML
Department of Psychiatry, Westchester Weill Medical College of Cornell University, White Plains, NY 10605, USA.

Neuropsychol Rev 1998 Sep;8(3):109-67
Differential diagnosis of the major progressive dementias and depression in middle and late adulthood: a summary of the literature of the early 1990s.
Rosenstein LD
Department of Psychiatry, Scott & White Clinic and Memorial Hospital, Temple, Texas 76508, USA.
There is a preponderance of research on the neuropsychology of the various dementias. There are also direct comparisons between two or more dementias available in the literature. This paper sought to summarize the most recent literature, primarily from 1990 through mid-1996, including recent reviews of the literature from previous decades. The purpose was to provide, in one location, a summary of neuropsychological (i.e., cognitive, motor, and psychiatric) characteristics of major noninfectious, progressive dementias and depression of middle and late adulthood. It is hoped that this review, particularly a summary table provided, will serve as a guide in the differential diagnosis of the dementias by clinicians. In addition to Alzheimer's disease, vascular dementias, Parkinson's disease, Lewy body dementia, Huntington's disease, and frontal lobe dementia, the impact of depression on cognitive functioning is covered given the frequency with which neuropsychologists are asked to differentiate depression from primary dementia.

J Neuropsychiatry Clin Neurosci 1998 Fall;10(4):440-7
Relationship of cognitive and functional impairment to depressive features in Alzheimer's disease and other dementias.
Payne JL, Lyketsos CG, Steele C, Baker L, Galik E, Kopunek S, Steinberg M, Warren A
Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA.
Patients with clinical diagnoses of Alzheimer's disease, vascular dementia, or undifferentiated dementia were rated on standardized measures of depression, cognitive impairment, and functional impairment. Logistic regression was used to evaluate the relationship between functional or cognitive impairment, as well as their interaction, and depressive features in each group. This analysis revealed notable differences by type of dementia. The results imply that the mechanisms underlying depression in Alzheimer's disease may be different from those in vascular and other types of dementia. These results also provide indicators to the clinician for further evaluation of depression in different dementia subtypes.

Depress Anxiety 1998;8 Suppl 1:91-5
Depression and Alzheimer's disease.
Tune LE
Wesley Woods Center on Aging, Emory University School of Medicine, Atlanta, Georgia 30329, USA.
Depressive symptoms, due either major depression or clinically significant, subsyndromal depression, occur commonly in the course of Alzheimer's disease. For a variety of clinical and methodological reasons, this remains an area that begs for new investigation. At the very least, these depressive symptoms should be viewed as a cause of significant and treatable "excess disability" (Kramer and Reifler, 1992). Demented patients with clinically significant depression (e.g., depressed mood, significant loss of appetite, insomnia, fatigue, irritability, and agitation) should be considered for a trial of antidepressant therapy, even when they fail to meet full diagnostic criteria for major depression. These symptoms will, in most instances, respond to antidepressant therapy. The "rules" for treatment of depression in dementia are slightly different than for cognitively intact patients: (a) start low, go slower, (b) pay attention to cognitive toxicity of all medication combinations, and (c) depressive symptoms do not persist as long as in cognitively intact patients. Current treatments, especially those SSRI's like fluoxetine and sertraline that have cognitive enhancing effects, should be considered the "first line" antidepressants. We need to emphasize early detection and treatment of depressive symptoms in dementia in all arenas.
Publication Types: Review
Am J Geriatr Psychiatry 1998 Fall;6(4):308-19
Disagreement in the reporting of depressive symptoms between patients with dementia of the Alzheimer type and their collateral sources.
Burke WJ, Roccaforte WH, Wengel SP, McArthur-Miller D, Folks DG, Potter JF
Department of Psychiatry, University of Nebraska College of Medicine, Omaha, USA. wjburke@unmc.edu
The authors investigated sources of disagreement on the Geriatric Depression Scale (GDS) between patients and their collateral sources (CSs). There were 198 subjects with possible or probable Alzheimer's disease (DAT) and 64 cognitively intact subjects evaluated at an outpatient geriatric assessment center. The 30-item GDS was completed by the patient and the CS version of the GDS by the CS. A sizable discrepancy was found in the reporting of depressive symptoms by the subjects vs. the CSs. Multiple-regression analyses revealed that both level of insight and level of physical illness in the subjects with DAT significantly influenced the discrepancy. An increased sense of burden in the CSs was associated with a larger symptom gap in both DAT and control subjects. CSs consistently perceived more depressive symptoms than subjects, especially subjects with DAT who had no insight into their cognitive impairment.

Biol Psychiatry 1998 Oct 1;44(7):592-9
Magnetic resonance imaging correlates of depression in early- and late-onset Alzheimer's disease.
Clark LM, McDonald WM, Welsh-Bohmer KA, Siegler IC, Dawson DV, Tupler LA, Krishnan KR
Psychology Department, University of North Carolina, Chapel Hill, USA.
BACKGROUND: Depressive symptoms are frequent complications of Alzheimer's disease (AD). We hypothesized that AD patients with depression would be more likely than nondepressed AD patients to show deep white-matter, subcortical gray-matter, and periventricular hyperintensities on magnetic resonance imaging (MRI). METHODS: In a retrospective study of 31 AD patients, depression was characterized by clinical diagnosis (DSM-III-R major depression, depressive symptoms, or no depression), a clinician-rated depression scale, and informant ratings of premorbid (before memory disorder) as well as current depression using the NEO Personality Inventory (NEO-PI), and related to qualitative and quantitative ratings of MRI hyperintensities. RESULTS: In contrast to reports in nondemented elderly patients, there was no relationship between clinical diagnosis of major depressive episode and hyperintensities; however, clinician-rated depressive symptoms were higher in subjects with large anterior hyperintensities. In the early-onset AD group only, MRI abnormalities were related to greater premorbid depression, and less increase in depression after the onset of dementia, as rated by informants on the NEO-PI. CONCLUSIONS: Results highlight the need to consider early- and late-onset AD separately when assessing relationships between personality and MRI abnormalities, and to consider premorbid personality style when drawing conclusions about the etiology of depressive features seen in AD.

Soc Psychiatry Psychiatr Epidemiol 1998 Oct;33(10):510-3
Differential validity of informant-based diagnoses of dementia and depression in index subjects and in their first-degree relatives.
Heun R, Muller H, Papassotiropoulos A
Department of Psychiatry, University of Bonn, Germany. heun@uni-bonn.de
There is no study indicating that informant-derived information on dementia and depression (i.e. family history information) is equivalently valid for first-degree relatives and for index subjects (i.e. patients and control subjects). However, this unproven assumption is the basis for the frequent, possibly inappropriate, use of instruments validated for patients and control subjects in family studies which focus on frequencies of psychiatric disorders in first-degree relatives. Consequently, there is a need to compare the validity of family history information for both disorders in index subjects and their first-degree relatives. Validity was assessed by comparison of family history information for dementia and depression with interview-derived diagnoses in 75 index subjects and 195 age-matched first-degree relatives. The validity of informant-derived information varied for different disorders, i.e. dementia and depression, and different samples, i.e. index subjects and first-degree relatives. In agreement with the study hypothesis, the sensitivity of surrogate information on dementia was significantly reduced in first-degree relatives in comparison with index subjects. In contrast, the sensitivity to detect depression was equivalent in subjects and in relatives. The results indicate the necessity to assess the validity of the psychiatric diagnoses of interest in the sample of interest, e.g. dementia or depression in first-degree relatives of patients and of control subjects. Observations in selected samples, i.e. subjects treated, hospitalised and/or autopsied, cannot be generalised to first-degree relatives in family studies.

Vojnosanit Pregl 1998 Jul-Aug;55(4):395-9
[Evaluation of the level of depression and dementia in patients with primary chronic active epilepsy using the Dementia Mood Assessment Scale].
[Article in Serbo-Croatian (Cyrillic)]
Djokic G, Milovic-Vujkovic M, Tomovic M, Makevic M
The study included 40 patients, aged 18-40 years with primary chronic active epilepsy, tested by clinical DMAS scale. We have found that the level of intelectual function damage (dementia) and mood (depression) rates depended on the long duration of epilepsy and the frequency of seizures, less on the frequency of specific EEG findings. Types of epileptic seizures and polytherapy influenced the depression and dementia rates the least in previous epilepsu treatment.

J Clin Psychiatry 1998;59 Suppl 9:38-44
Diagnosis and treatment of depression in patients with Alzheimer's disease and other dementias.
Katz IR
Department of Psychiatry, University of Pennsylvania, Philadelphia, USA.
Depressive disorders--both major depression and other less severe but nonetheless clinically significant depressions--are common comorbidities, components, or complications of dementia. Depression with reversible cognitive impairment may be a prodrome for dementia rather than a separate and distinct disorder. Recent research has demonstrated that both the diagnosis of major depression and the assessment of typical depressive symptoms can be conducted reliably, even in patients with mild-to-moderate levels of cognitive impairment. Self-ratings of depressive symptoms with the Geriatric Depression Scale remain valid in patients with Mini-Mental State Examination scores of at least 15. Among interviewer-administered instruments, the Hamilton Rating Scale for Depression and the Cornell Scale are the best established. Potential difficulties with assessment include problems with ascertainment (because families, in general, report greater depression in patients than do clinicians) and the ambiguity of symptoms (because apathy and related symptoms can result from both depression and Alzheimer's disease). Brain changes due to Alzheimer's disease may lead to fundamental differences in drug responses. Nevertheless, randomized clinical trials have demonstrated that depression in dementia responds to specific psychopharmacologic or psychosocial treatments.

J Clin Psychiatry 1998;59 Suppl 10:9-12
The clinical interface of depression and dementia.
Raskind MA
Veterans Affairs Puget Sound Health Care System, Mental Health Service, and the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle 98108, USA.
The interface between depression and dementia is complex and has been studied primarily in Alzheimer's disease. This article discusses several aspects of this intriguing area of clinical research, including depressive pseudodementia and the possibility that depression may be a risk factor for the expression of Alzheimer's disease in later life and that depression may occur as a prodrome for this most common dementing disorder. In addition, the treatment challenges faced by clinicians when depression complicates the course of Alzheimer's disease are addressed. It is likely that a combination of behavioral treatment and use of antidepressant medication will provide the optimal management of depression in Alzheimer's disease.

J Neural Transm Suppl 1998;53:91-5
Problems of differential diagnosis between depressive pseudodementia and Alzheimer's disease.
Zapotoczky HG
Department of Psychiatry, University of Graz, Austria.
Today, pseudodementia seems to be a blurred and misleading term. It is more precise to speak about cognitive disorders which can be observed in both depressed and demented patients. Guidelines which can help to differentiate between depression and dementia are proposed for both the history and the course of the disorders. Additional brain imaging can give further indications. Ergopsychometric setting, which obeys directed burden under speed conditions may be helpful. SSRIs may reduce the HPA axis hyperactivity in depressive patients with Alzheimer disease. Therefore this medication can help to improve the state of these patients.

Am J Geriatr Psychiatry 1998 Summer;6(3):212-20
The factor structure of the Cornell Scale for Depression in Dementia among probable Alzheimer's disease patients.
Harwood DG, Ownby RL, Barker WW, Duara R
Wien Center for Alzheimer's Disease and Memory Disorders, Mount Sinai Medical Center, Miami Beach, FL 33140, USA.
The authors rated 137 outpatients with probable Alzheimer's disease (AD) on the Cornell Scale for Depression in Dementia (CSDD) as part of routine evaluation. Principal-factors analysis with varimax rotation resulted in a four-factor solution that accounted for 43.1% of the common variance. The four factors included general depression (lack of reactivity to pleasant events, poor self-esteem, pessimism, loss of interest, physical complaints, psychomotor retardation, sadness); rhythm disturbances (difficulty falling asleep, multiple night awakenings, early morning awakenings, weight loss, diurnal variation of mood); agitation/psychosis (agitation, mood-congruent delusions, suicide); and negative symptoms (appetite loss, weight loss, lack of energy, loss of interest, lack of reactivity to pleasant events). The observed factor structure showed moderate concordance with the five symptom clusters proposed in the original presentation of the CSDD.

Int J Geriatr Psychiatry 1998 May;13(5):298-309
An informant interview for the diagnosis of dementia and depression in older adults (IDD-GMS).
Lewis S, Hinchcliffe K, Katona C, Livingston G
Department of Psychiatry and Behavioural Sciences, University College London Medical School, UK.
BACKGROUND: There has been no instrument developed for the differential diagnosis of psychiatric conditions using an informant. The present study describes the development and validation of an informant interview for the diagnosis of dementia and depression in older adults (IDD-GMS). The IDD-GMs, as its name indicates, is based upon the well-established Geriatric Mental State Schedule (GMS). METHOD: Thirty older adults with psychiatric illnesses were identified. An informant/career was interviewed using the IDD-GMS. Questions from the GMS were altered to reflect the informant nature of interview. Validity was compared to ICD-10 diagnoses. Interrater reliability was determined. RESULTS: Using a hierarchical diagnostic system, receiver operating characteristics demonstrated one optimal cutpoint for sensitivity, > 13 for dementia and > 16 for depression, and one for specificity, > 13 for dementia and > 10 for depression. CONCLUSION: The validity and reliability of the IDD-GMS falls within acceptable limits and indicates that the IDD-GMS can be used as a diagnostic instrument for dementia and depression. The IDD-GMS represents the first informant interview to achieve this.

Alzheimer Dis Assoc Disord 1998 Jun;12(2):62-70
Psychological morbidity in caregivers is associated with depression in patients with dementia.
Brodaty H, Luscombe G
Academic Department of Psychogeriatrics, Prince Henry Hospital, School of Psychiatry, University of New South Wales, Sydney, Australia. research.adpg@unsw.edu.au
The relationship between psychological morbidity in caregivers and depression in patients with dementia was examined using data collected on 193 patient-caregiver dyads attending a memory disorders clinic. Caregivers had high rates and levels of psychological morbidity which were associated with the severity of dementia (but neither the type nor duration), with the caregiver being a spouse and female and living with the person with dementia. A logistic regression analysis identified clinician-rated patient depression score and demanding problem behaviors as being independently and significantly associated with caregiver psychological morbidity. This new finding of a link between patient depression and caregiver psychological morbidity has implications for more focused treatment programs for both caregivers and patients.

Neuroimage 1998 Apr;7(3):199-208
A voxel-based analysis of cerebral perfusion in dementia and depression of old age.
Ebmeier KP, Glabus MF, Prentice N, Ryman A, Goodwin GM
MRC Brain Metabolism Unit, University of Edinburgh, United Kingdom. k.ebmeier@ed.ac.uk
Thirty-nine elderly depressed patients as well as 15 demented patients with Alzheimer's disease and 11 healthy volunteers were imaged at rest with a high resolution single-slice 12-detector head scanner (SME-Neuro 900) and the cerebral perfusion marker 99mTc-Exametazime (HM-PAO). Statistical parametric maps were computed to compare early- and late-onset depressed, Alzheimer patients and healthy volunteers and to examine associations between regional perfusion and clinical and MRI variables. Patients with late-onset depression showed reductions in temporal lobe perfusion compared with early-onset depression and controls. Alzheimer patients had the expected reduced perfusion in temporoparietal and prefontal cortex, as well as basal ganglia, compared with healthy controls. Compared with depressed patients, they showed a relative reduction in temporoparietal cortex, only. This difference was more pronounced between Alzheimer patients and early onset, compared to late-onset patients with depression. Periventricular white matter changes on MRI were associated with temporal lobe reductions of tracer uptake in depression. In the Alzheimer group, deep white matter MRI changes were associated with frontal perfusion deficits. Our results support a vulnerability hypothesis, which predicts that patients with late-onset depression will show more brain changes than patients with an early onset of their illness. Statistical parametric mapping in patients with organic psychiatric brain syndromes is feasible and promising as a clinical and research method.

Am J Geriatr Psychiatry 1998 Spring;6(2):162-75
Depression among African American nursing home patients with dementia.
Cohen CI, Hyland K, Magai C
SUNY Health Science Center at Brooklyn 11203, USA.
The authors compared 218 black and 68 white nursing home patients with dementia for differences in the prevalence, recognition, and treatment of depression. There were no racial differences in depressive symptoms, but whites were significantly more likely to receive a diagnosis of "possible depression" and there were few racial differences in clinical, social, or demographic factors associated with depression. Depression was often unrecognized and undertreated in both racial groups; several depression instruments developed for use in dementia had good reliability and validity among blacks; and there were no significant differences in depressive symptoms or diagnosis between U.S.-born and Caribbean-born black patients. The absence of any appreciable interracial or intraracial differences in depression symptoms or diagnoses may reflect uniformity in nursing home selection criteria or lessening of mood differences that may have existed before admission.

Int Psychogeriatr 1997 Dec;9(4):449-57
Factor structure of the Dementia Mood Assessment Scale in a cohort of community-dwelling elderly.
Onega LL, Abraham IL
Oregon Health Sciences University, Portland 97201-3098, USA.
We examined the factor structure of the 28-item Dementia Mood Assessment Scale (DMAS), an instrument to assess depressive symptoms in older adults with cognitive impairment, in a cohort of 165 community-dwelling elderly with varying degrees of cognitive impairment. Factor analysis using principal components analysis and varimax rotation was performed to explore the presence of subscales and examine construct validity. A five-factor structure involving all 28 items accounting for 63.2% of the variance in the DMAS scores was derived. Factors were named: Depressed Affect, Environmental Interaction, Diurnal Patterns, Agitation/Suspicion, and Somatic Indicators. This factor structure reflects the often differing presentations of depressive symptoms in older adults with varying degrees of cognitive function and establishes the construct validity of the DMAS in this population. We conclude that the DMAS may be used for differentiated clinical assessment of depressive symptoms along major dimensions of depressive illness in this cohort of elderly.

J Neuropsychiatry Clin Neurosci 1998 Winter;10(1):64-7
Olfactory dysfunction discriminates Alzheimer's dementia from major depression.
Solomon GS, Petrie WM, Hart JR, Brackin HB
This study tested the hypothesis that olfactory dysfunction could discriminate between groups of patients with Alzheimer's disease and major depression. Forty patients meeting DSM-IV criteria for Alzheimer's disease and for major depression (20 per group) underwent assessment with the Pocket Smell Test (PST), a three-item screening measure of cranial nerve I function. A PST score of < or = 1 (1 or 0 correct) discriminated between the groups with a hit rate of 90% (sensitivity = 80%, specificity = 100%). Olfactory assessment may be a useful adjunctive screening measure in differentiating Alzheimer's disease from depression in elderly patients.

26: Rev Neurol 1998 Jan;26(149):57-60
[Prevalence of depressive disorders in dementia].
[Article in Spanish]
Vilalta-Franch J, Lopez-Pousa S, Llinas-Regla J
Unitat de Valoracio de la Memoria i les Demencies, Hospital Santa Caterina, Girona, Espana.
OBJECTIVE: To find the prevalence of depressive illness associated with dementia in our geriatric population. MATERIAL AND METHODS: A study was made of the entire population aged over 69 years in eight rural districts of the province of Girona (Spain). Diagnosis was made using CAMDEX criteria. RESULTS: The prevalence of depression (depressive disorders plus pseudo dementia) was 9.1% (IC = 7.6-10.5%). In the group of patients with dementia, the frequency of depression was 28.15% whilst in the group with no dementia it was 5.4% (p = 0.0000). No differences were seen in the prevalence of depression between patients with Alzheimer type dementia (ATD) and those with vascular dementia (VD). The gravity of dementia, sex and age did not influence the frequency of depression. CONCLUSIONS: Depression in patients with dementia was very frequent in our geriatric population. Dementia was seen to be a risk factor with regard to depression.

Int J Geriatr Psychiatry 1998 Feb;13(2):100-8 A double-blind comparison of the efficacy and safely of paroxetine and imipramine in the treatment of depression with dementia.
Katona CL, Hunter BN, Bray J
Department of Psychiatry and Behavioural Sciences, UCL Medical School, London, UK.
OBJECTIVES: To compare the efficacy of paroxetine and imipramine prospectively in patients with coexisting depression and dementia. METHODS: An 8-week, double-blind, parallel group trial comparing paroxetine 20-40 mg/day with imipramine 50-100 mg/day in 198 patients aged 60 years or over with a Montgomery-Asberg Depression Rating Scale (MADRS) score > or = 20 and a Folstein mini-mental state evaluation score of 17-23 points after a 3- to 7-day placebo run-in period. RESULTS: Both paroxetine and imipramine reduced the MADRS and the Clinical Global Impression (CGI) severity-of-illness and global improvement scores at weeks 2, 4, 8 and at endpoint, with no significant differences between treatment groups at any timepoint (MADRS, p > or = 0.368; cgi, p > or = 0.286). There was a statistically significant difference in favour of paroxetine at both the week 4 and week 8 timepoints (analysis of variance, p < or = 0.049) in the Cornell scale for depression in dementia: at endpoint there was no significant difference between treatments (p = 0.103). Treatment-emergent adverse experiences were reported by 51.5% (51/99) of patients treated with paroxetine and 50.5% (50/99) of patients treated with imipramine. Anticholinergic adverse experiences (paroxetine 6.1%; imipramine 13.1%) and serious non-fatal adverse experiences (paroxetine 4.0%; imipramine 8.1%) were reported by more patients in the imipramine group than in the paroxetine group. CONCLUSIONS: Paroxetine and imipramine were both effective in the treatment of depression in elderly subjects with co-existing dementia, and no significant differences were detected between the groups. There were trends suggesting that paroxetine was better tolerated than imipramine in terms of anticholinergic adverse experiences and serious non-fatal adverse experiences.

J Neuropsychiatry Clin Neurosci 1997 Fall;9(4):556-61
Major and minor depression in Alzheimer's disease: prevalence and impact.
Lyketsos CG, Steele C, Baker L, Galik E, Kopunek S, Steinberg M, Warren A
Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA. One hundred nine outpatients with Alzheimer's disease (AD) were neuropsychiatrically evaluated and rated on standardized measures of depression, activities of daily living (ADL), nonmood behavioral disturbance, and burdensome events such as serious wandering, falls, and accidents. Distribution of depression scores revealed three patient groups: very few depressive symptoms (51%), minor depression (27%), and major depression (22%). Major depression was associated with substantially greater impairment in ADL, worse nonmood behavioral disturbance (such as aggression), and more frequent serious wandering, even after adjusting for severity of dementia or comorbid health problems. Minor depression was also associated with nonmood behavioral disturbance and wandering. The authors conclude that both major and minor depression are common in AD and produce considerable mood and nonmood morbidity affecting both patients and caregivers. Efforts are warranted to identify and treat depression in AD.

Int Psychogeriatr 1997;9 Suppl 1:59-64
Diagnosing Alzheimer's disease in the presence of mixed cognitive and affective symptoms.
Reifler BV
Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, North Carolina 27157-1087, USA.
Dementia and depression are the two most common mental illnesses in late life, and it is probable that they will coexist in many patients. This coexistence is complicated by the fact that both illnesses can be mistaken for each other, so that many patients with Alzheimer's disease (AD) may initially be diagnosed as depressed, whereas depression is a recognized cause of cognitive impairment. It is important to correctly differentiate between these two diagnoses; if depression is the cause of the cognitive impairment, full recovery is possible. It is also important to recognize depression in patients with AD, because depression represents a treatable source of additional disability. For patients with AD living in the community, functional limitation can determine whether the patient remains at home or is institutionalized, so treatment that can improve functional ability should be strongly considered. The newer antidepressants are better tolerated without increase in cost, so these drugs may provide a therapeutic advantage over the older tricyclic drugs. This article focuses primarily on techniques for establishing a differential diagnosis, with particular emphasis on patients in the primary care setting, and briefly considers the value and impact of treatment.

J Am Geriatr Soc 1998 Jan;46(1):27-30
Major depression in a population of demented and nondemented older people: prevalence and correlates.
Forsell Y, Winblad B
Stockholm Gerontology Research Centre, Karolinska Institute, Sweden.
OBJECTIVE: To analyze the differences between variables associated with depression and symptoms of depression in demented and nondemented persons. DESIGN: A survey design was used. SETTING/PARTICIPANTS: A total of 1101 older persons registered in a district of Stockholm, Sweden, participated in the study. MEASUREMENTS: Subjects were given physical and psychiatric examinations by physicians, and informants interviews and medical records were assessed. Dementia was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) criteria and major depression according to DSM-IV. The variables studied were age, gender, martial status, institutionalization, Mini-Mental State Exam score, disability in daily life, physical disorders with symptoms affecting daily life, and a previous history of depression (early and late). RESULTS: 27.8% of the patients in the study sample were demented according to DSM-III-R. Major depression was diagnosed in 3.9% of the nondemented and in 11.8% of the demented subjects. Some of the depressive symptoms, such as lack of energy, thinking/concentration difficulties, loss of interest, and psychomotor disturbance, were found more commonly in demented than in nondemented persons. Increased disability was associated with major depression both in demented and nondemented persons. CONCLUSION: In this study, the prevalence of depression was higher in demented than in nondemented persons. Among the factors that were studied, increased disability was associated with depression both in demented and nondemented persons. No differences were found regarding the other studied variables.
PMID: 9434662

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