Relationship of endothelial function and atherosclerosis to treatment response in late-life depression.

OBJECTIVE: Treatment response in late-life depression has been linked to cerebrovascular disease notably via the vascular depression hypothesis. This study investigated the relationship between endothelial function and atherosclerosis and treatment response to antidepressant monotherapy. METHODS: Twenty five patients with late-life depression were compared with 21 non-depressed control subjects in a case control study. Nine of the depressed subjects were responders to antidepressant monotherapy and 16 were not. Vascular measures included assessment of carotid intima media thickness (IMT) representing atherosclerosis and biopsied small artery dilatation to acetylcholine to assess endothelial function in a subset of subjects. RESULTS: There were no group differences in vascular risks or sociodemographic variables. There was a significant group difference (responders versus non-responders versus controls) on both IMT and endothelial function (p < 0.01 and p < 0.05, respectively) with a significant difference between controls and non-responders (p < 0.001) on IMT and between controls and responders (p < 0.05) and control versus non-responders (p < 0.05) on endothelial function but no significant difference between responders and non-responders. On both IMT and endothelial function, there was a gradient across groups, with control subjects having best vascular structure or function, non-responders worse and responders in-between. CONCLUSIONS: The results are consistent with a hypothesis that poorer antidepressant response in later life depressive disorder may be linked to an underlying vascular dysfunction and pathology. The study is small, and the results require replication but if confirmed, trials with vasoprotective medication aimed at improving vascular function in order to alter the prognosis of late-life depression would be a rational development.

Depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease: prevalence, relevance, clinical implications and management principles.

OBJECTIVE: To review evidence regarding the prevalence, causation, clinical implications, aspects of healthcare utilisation and management of depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease. DESIGN: A critical review of the literature (1994-2009). FINDINGS: The prevalence of depression and anxiety is high in both chronic obstructive pulmonary disease (8-80% depression; 6-74% anxiety) and chronic heart failure (10-60% depression; 11-45% anxiety). However, methodological weaknesses and the use of a wide range of diagnostic tools make it difficult to reach a consensus on rates of prevalence. Co-morbid depression and anxiety are associated with increased mortality and healthcare utilisation and impact upon functional disability and quality of life. Despite these negative consequences, the identification and management of co-morbid depression and anxiety in these two diseases is inadequate. There is some evidence for the positive role of pulmonary/cardiac rehabilitation and psychotherapy in the management of co-morbid depression and anxiety, however, this is insufficient to guide recommendations. CONCLUSIONS: The high prevalence and associated increase in morbidity and mortality justifies future research regarding the management of anxiety and depression in both chronic heart failure and chronic obstructive pulmonary disease. Current evidence suggests that multi-faceted interventions such as pulmonary and cardiac rehabilitation may offer the best hope for improving outcomes for depression and anxiety.

Swallowing problems and dementia in acute hospital settings: practical guidance for the management of dysphagia.

There is little evidence to support tube feeding in advanced dementia although it is still frequently used in acute hospital settings. Patients present with complex problems and are often unable to make decisions about their healthcare needs. Multidisciplinary teams may be challenged by the difficult ethical decisions they are required to make in the best interests of their patients. This paper guides decision making in the management of patients with dementia and dysphagia in the acute hospital setting. A structured approach to information gathering, assessment and management is outlined with practical application of recent published guidelines and research evidence, which ensures appropriate individualised care.

Prevalence of depression and anxiety symptoms in elderly patients admitted in post-acute intermediate care.

OBJECTIVES: Depression and anxiety symptoms are common in medically ill older patients. We investigated the prevalence and predictors of depression and anxiety symptoms in older patients admitted for further rehabilitation in post acute intermediate care. DESIGN: Observational cohort study. SETTING: An intermediate care unit, North West of England. PARTICIPANTS: One hundred and seventy-three older patients (60 male), aged mean (SD) 80 (8.1) years, referred for further rehabilitation to intermediate care. MEASUREMENTS: Depression and anxiety symptoms were assessed by the Hospital Anxiety and Depression Scale, and severity of depression examined by the Montgomery Asberg Depression Rating Scale. Physical disability was assessed by the Nottingham Extended ADL Scale and quality of life by the SF-36. RESULTS: Sixty-five patients (38%) were identified with depressive symptoms, 29 (17%) with clinical depression, 73 (43%) with anxiety symptoms, and 43 (25%) with clinical anxiety. 15 (35%) of the latter did not have elevated depression scores (9% of the sample). Of those with clinical depression, 14 (48%) were mildly depressed and 15 (52%) moderately depressed. Longer stay in the unit was predicted by severity of depression, physical disability, low cognition and living alone (total adjusted R2 = 0.24). CONCLUSIONS: Clinical depression and anxiety are common in older patients admitted in intermediate care. Anxiety is often but not invariably secondary to depression and both should be screened for. Depression is an important modifiable factor affecting length of stay. The benefits of structured management programmes for anxiety and depression in patients admitted in intermediate care are worthy of evaluation.

Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2000 British Association for Psychopharmacology guidelines.

A revision of the 2000 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in May 2006. Key areas in treating depression were reviewed, and the strength of evidence and clinical implications were considered. The guidelines were drawn up after extensive feedback from participants and interested parties. A literature review is provided, which identifies the quality of evidence to inform the recommendations, the strength of which are based on the level of evidence. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse, and stopping treatment.

Health behaviour, depression and religiosity in older patients admitted to intermediate care.

OBJECTIVE: To examine health behaviour, severity of depression, gender differences and religiosity in older patients admitted to intermediate care for further rehabilitation. DESIGN: Cross-sectional survey. PARTICIPANTS: A research physiotherapist interviewed 173 older patients (113 female), 60 and older consecutively admitted to intermediate care for rehabilitation, usually after acute care. MEASUREMENTS: Religiosity was measured using the Duke University Religion Index, depressive and anxiety symptoms using the Hospital Anxiety Depression Scale, and severity of depression measured by the Montgomery Asberg Depression Rating Scale. Physical disability was assessed by the Nottingham Extended Activities of Daily Living Scale and quality of life measured by the SF-36 questionnaire. RESULTS: After controlling for other factors using multiple regression, religious attendance was associated with positive general health perception (t = 1.9, p = 0.05), and inversely associated with number of pack years smoked (t = -2.05, p = 0.04) and severity of illness (Charlson Index), [t = -2.05, p = 0.04]. Intrinsic religious activity was associated with older age (t = 3.06, p < 0.003), female gender (t = 2.52, p = 0. 01), living situation (t = -2.17, p < 0.03) and with less severe depression (t = -2.43, p = 0.01). CONCLUSION: In older patients with chronic diseases in intermediate care, religious attendance was associated with positive perceptions of health, less severe illness, and fewer pack years. Intrinsic religious activities were associated with less severe depression and lower likelihood of living alone.

Management strategies in geriatric depression by primary care physicians and factors associated with the use of psychiatric services: a naturalistic study.

Approximately 10% of elderly patients in primary care have depression yet it is often under-diagnosed and under-treated. It is unclear exactly how patients are being managed in primary care or what factors are associated with referral to psychiatric services. This study aimed to establish in a naturalistic setting how older depressed patients are managed in primary care; to determine which patients are referred to psychiatric services and the differences between patients referred and those not; in terms of primary care consultation rate and degree of co-morbid illness. Computerised records and referral letters were read for 1089 elderly patients in a large practice in central Manchester, UK. Of the 9% identified as depressed, 90% were managed in primary care alone, a third without antidepressants. More than half of those prescribed antidepressants received tricyclic antidepressants. Suicidal ideation and treatment failure were the principle reasons for referral. Patients referred had a greater psychiatric co-morbidity and had consulted their GP more frequently in the past year. Management of depression in the elderly may be conservative and older antidepressants may be over-prescribed. Increased primary care consultation rate and a greater psychiatric co-morbidity may be associated with referral to psychiatric services.

Right-hemisphere encephalopathy in elderly subjects with schizophrenia: evidence from neuropsychological and brain imaging studies.

RATIONALE: Cognitive impairment is a recognised feature of schizophrenia. Elderly patients with early-acquired schizophrenia are seriously affected, with a proportion of them showing clinically significant dementia, not accounted for by any recognized degenerative processes common in this age group, such as Alzheimer's disease. Progression of cognitive deficits is described in elderly institutionalised patients, but disputed amongst community dwelling subjects. The pattern of cognitive deficits in this age group is not yet clearly defined, although there is some evidence that it differs from that in Alzheimer's disease. There is little evidence of any underlying specific brain abnormality. OBJECTIVES: To characterize the neuropsychological deficits in elderly schizophrenia patients and distinguish them from those in Alzheimer's disease. To establish the presence of underlying structural brain abnormality using MRI. METHODS: Twenty-eight elderly schizophrenia patients with onset before the age of 45 years carried out neuropsychology tests. Twelve scored in the dementia range and were compared with 16 equally impaired patients with early Alzheimer's disease. Thirteen of the schizophrenia patients consented to brain MRI. The imaging data were analysed using a newly developed automated method of measuring CSF volume distributions and compared with data from 30 age-matched normal controls. RESULTS: The schizophrenia group was more impaired on visuo-spatial tasks than the Alzheimer's group but less impaired on corresponding verbal tasks, despite similar overall cognitive impairment. The MR scans revealed right-sided enlargement of ventral CSF spaces in the schizophrenia patients especially in the posterior third, and this correlated with their impaired performance on visuo-spatial tasks. CONCLUSIONS: The results suggest that right hemisphere impairment underlies the specific profile of cognitive impairment in elderly patients with schizophrenia.

A feasibility study of antidepressant drug therapy in depressed elderly patients with chronic obstructive pulmonary disease.

OBJECTIVES: To examine the acceptability of fluoxetine in elderly depressed patients with chronic obstructive pulmonary disease (COPD). SETTING: A university teaching hospital. METHOD: Single-blinded (open) study. One hundred and thirty-seven outpatients (69 male) with symptomatic irreversible, moderate to severe COPD were recruited. Major depression was diagnosed using the Geriatric Mental State Schedule. Quality of life was assessed by the Breathing Problems Questionnaire, physical disability by the Manchester Respiratory Activities of Daily Living Questionnaire and severity of depression using the Montgomery Asberg Depression Rating Scale. Exclusion criteria were: use of oral steroids within 6 weeks, acute or chronic confusion, known cancer and known psychosis. RESULTS: Fifty-seven patients (42%) (25 males) with a mean age of 72 years (range 60-89 years) were depressed. Fourteen (six male) agreed to undergo therapy with fluoxetine 20 mg/day for 6 months, while 36 (72%) refused antidepressant drug therapy. Only seven subjects completed the trial; of these, four (57%) responded to fluoxetine therapy. Five subjects withdrew because of side-effects. Twenty-two of those who refused treatment (61%) agreed to be interviewed, and of these 19 (86%) were still depressed. CONCLUSION: Patient acceptance of fluoxetine was poor. The reasons for refusing treatment varied but were largely due to misapprehension by the patient. Untreated depression became chronic. Offering antidepressants to COPD patients with depression is not an effective strategy. Why this might be so is discussed.

Regional cerebral volume measurements in late-life depression: relationship to clinical correlates, neuropsychological impairment and response to treatment.

BACKGROUND: Elderly people who develop depression have demonstrable changes in cerebral structure but little is known of the relationship between regional cerebral volumes, treatment response and cognitive impairment. METHOD: Forty-four patients with major depression diagnosed according to DSM-IIIR criteria underwent magnetic resonance imaging and regional cerebral volumes were quantified using multispectral analysis. Response to antidepressant treatment was assessed prospectively and a neuropsychological test battery was administered. RESULTS: There was a trend for smaller fronto-temporal volumes in the treatment-resistant patients. Impaired immediate working memory was linked with reduced frontal and parietal lobe volume and impaired short-term memory functioning was associated with reduced temporal lobe volume. Ventricular enlargement was associated with prior administration of electro-convulsive therapy, poor physical health and later age at onset of first episode of depression. CONCLUSION: In late-life depression, brain changes should not preclude vigorous antidepressant treatment. Regional cerebral volume changes may be a complication of poor physical health and are associated with memory dysfunction even upon recovery from depression.

Poor prognosis of depression in elderly people: causes and actions.

Depression is the most common mental health problem of older people. It is a serious disorder which can lead to persistent suffering, increased mortality, from both suicide and general medical causes, and poorer overall health. Although presenting symptoms are similar in all age groups there are different aetiological pathways. In older people the waning effect of genetic predisposition to affective disorder may be replaced by subcortical brain abnormalities of presumed vascular aetiology. These may influence prognosis. Depression in later life is often under-diagnosed and under-treated; these two factors are the main hurdles to an improved prognosis. Antidepressant treatment should be tailored to the patient and works best when combined with psychological therapy, but the latter treatment modality is woefully neglected in later life psychiatry. Improvements in prognosis are unlikely to come from new revolutionary treatments but from vigorous treatment in the acute phase, continuation after recovery for at least 12-18 months and long-term maintenance treatment for those at high risk of recurrence.

Depression and anxiety in elderly outpatients with chronic obstructive pulmonary disease: prevalence, and validation of the BASDEC screening questionnaire.

OBJECTIVES: Depressive and anxiety symptoms are common in elderly patients with chronic obstructive pulmonary disease (COPD). However, true prevalence of clinical depression and anxiety is uncertain. We thus aimed to assess prevalence of clinical depression and/or anxiety in elderly COPD patients using the Geriatric Mental State Schedule (GMS) and determine severity of clinical depression by the Montgomery Asberg Depression Rating Scale (MADRS). We also aimed to validate the Brief Assessment Schedule Depression Cards (BASDEC) screening test for depressive symptoms against GMS. SETTING: A university teaching hospital. PARTICIPANTS: Subjects comprised 137 (69 men) outpatients with COPD, aged 60 - 89 (mean 73) years. Exclusion criteria were acute respiratory exacerbation or use of oral corticosteroid within 6 weeks, known psychosis, acute or chronic confusion. MEASUREMENTS: A GMS score > or =3 is diagnostic of clinical depression, and a BASDEC score > or =7 is classed as "case". GMS was taken as gold standard. Severity of depression was assessed by the MADRS: RESULTS: Mean (SD) one second forced expiratory volume was 0.89 (0.3) litres. Sixty-two subjects (46%) scored as a "case" on BASDEC and 57 subjects (42%) were identified as clinically depressed on GMS. In the depressed the prevalence of anxiety was 37% and in the non-depressed 5%. BASDEC performed well against GMS, having a sensitivity of 100%; a specificity of 93%; a positive predictive value of 91% and a negative predictive value of 100%. Assessment of severity of depression by MADRS showed that 17 subjects (30%) were mildly depressed, 39 (68%) were moderately depressed and one (2%) was severely depressed. CONCLUSION: Clinical depression and anxiety are common in elderly patients with COPD, though clinical anxiety seems mainly confined to those who also suffer clinical depression. Of those depressed, two-thirds scored in the moderately depressed range. BASDEC is a valid screening tool in this patient group.

The prognostic significance of abnormalities seen on magnetic resonance imaging in late life depression: clinical outcome, mortality and progression to dementia at three years.

OBJECTIVE: To study the course of depressive symptoms over 3 years, rate of dementia and mortality in relation to baseline neuroradiological abnormalities. DESIGN: Retrospective casenote analysis of 38 patients (of 44) who had a Magnetic Resonance Imaging (MRI) scan 3 years earlier. Twenty-two patients also received a detailed interview. RESULTS: Overall outcome was good for around two-thirds of the sample. Poorer clinical course was associated with lesions in pons and more than five Virchow Robins spaces in the corona radiata. Pontine raphe lesions and confluent periventricular lesions were associated with later dementia and with reduced survival from cardiovascular death. Males had more recurrences and a reduced survival. CONCLUSIONS: MRI lesions influence outcome, mortality and the onset of dementia. However, because they are quite common in elderly depressed patients they have limited utility on their own as predictors of outcome. The association of periventricular lesions with dementia is a new finding, and suggests that the site and type of lesions may be as important than the quality of them.

Is the clinical expression of late-life depression influenced by brain changes? MRI subcortical neuroanatomical correlates of depressive symptoms.

BACKGROUND: "Vascular depression" has recently been proposed. It is characterized by magnetic resonance imaging (MRI) T2-weighted subcortical lesions, a late onset of first episode of depression, and reduced heritability; a cerebrovascular etiology is suggested. The validity of "vascular depression" might be strengthened if an association was found between the subcortical lesions used to define it and particular depressive symptoms. METHODS: A blinded cross-sectional examination of DSM-III-R depressive symptoms (American Psychiatric Association, 1987) and MRI T2-weighted subcortical lesions in 44 patients with late-life depression. RESULTS: Many associations were found; however, because of multiple comparisons, their significance is viewed with caution. The most robust finding was that psychomotor retardation was independently related to total white-matter score. The odds of showing psychomotor retardation was increased 1.9 times for every point increase in severity of white-matter change. CONCLUSION: In late-life depression the clinical expression of the depression is influenced by the pattern of MRI T2-weighted subcortical lesions. This gives some validity to the concept of an MRI-defined "vascular" subtype of late-life depression and strengthens the argument for including neuroimaging in the classification of late-life depression.

The day hospital debate--a contribution.

OBJECTIVE: To compare the prevalence of difficult behaviours in confused older people attending a National Health Service (NHS) day hospital with those attending non-NHS day care facilities. DESIGN: A behavioural rating scale was completed and referral information collected for people with dementia attending day care services. SETTING: One day hospital and seven day care facilities in one UK health authority. PATIENTS: All 20 attenders at an NHS day hospital and 64 attending day care, the latter identified by the staff as 'confused'. MEASURES: A 15-item behaviour rating scale. RESULTS: The quantitative ratings showed more disturbance (restlessness, friction, sexual disinhibition), poorer memory and decreased mobility in the NHS attenders. These small differences concealed much greater qualitative differences in the methods of operation of the two types of facility, with the focus being on assessment and throughput in the day hospital and social support in the day care services. CONCLUSIONS: In the light of recent debate, this study has demonstrated small but measurable behavioural differences between an NHS day hospital and non-specialist day care. However, a focus on rating of behaviour alone conceals much greater differences in why people are referred, by whom and for what reasons. The day hospital has its own role and is not merely plugging a gap.

The differentiation of DSM-III-R psychotic depression in later life from nonpsychotic depression: comparisons of brain changes measured by multispectral analysis of magnetic resonance brain images, neuropsychological findings, and clinical features.

BACKGROUND: Psychotic depression has been proposed as a distinct subtype of major depression. There is considerable evidence for this in younger patients, although the neuroimaging has been rudimentary. Volumetric imaging studies are required of consecutive cohorts of patients with depression. METHODS: Ninety-nine consecutive elderly patients were diagnosed with DSM-III-R major depression. Eighteen were psychotic, and 81 were not. Sixty-six patients were given a neuropsychological test battery, and 44 had a magnetic resonance imaging brain scan. A model integrating clinical, psychological, and neuroimaging findings for the explanation of delusion formation during depression is proposed. RESULTS: Psychotic depression was characterized by worse physical health, more family history of depression, a poorer response to antidepressant drugs, and more severe lowering of mood; however, the strongest predictors of the presence of delusions were diencephalic atrophy, reticular activating system lesions, brain stem atrophy, and left-sided frontotemporal atrophy. The psychotic patients had poorer performance on tests of frontal lobe function and mental processing speed. CONCLUSIONS: In the elderly, psychotic depression is etiologically, clinically, and neuroradiologically distinct, and has different treatment requirements, from nonpsychotic major depression.