The prevalence of dementia and depression in the elderly community in a southern European population. The Zaragoza study.

BACKGROUND: Provocative international disparities reported in the prevalence rates of dementia and depression require further investigation. This is the first psychiatric study, to the best of our knowledge, about the prevalence of DSM-III-R dementing and depressive disorders and their relationships in a representative, stratified community sample of the elderly in both a Spanish-speaking country and southern Europe. METHODS: A two-stage screening was completed in 1080 elderly. Sampling with replacement was done, and the cumulative response rate was 88%. In phase 1, lay interviewers administered the Spanish versions of the Mini-Mental State examination and the Geriatric Mental State Schedule-Automated Geriatric Examination for Computer Assisted Taxonomy package. In phase 2, research psychiatrists administered the same instruments and the History and Aetiology Schedule to all the probable cases and a similar number of randomly selected, probably normal subjects. RESULTS: An estimated 5.5% of the elderly were considered to have a dementing disorder, the most prevalent types being primary degenerative dementia, Alzheimer's type (4.3%), and multi-infarct dementia (0.6%). Depressive disorders were found in 4.8% of the elderly. Psychiatric morbidity, specifically depression, was associated with lower educational levels. "Case levels" of depression were documented in 25.4% of the demented cases and case levels of "organic" disturbance were seen in 18.2% of cases of major depression. CONCLUSIONS: Among the elderly, the prevalence of Alzheimer's disease and multi-infarct dementia, as opposed to depression, increases steeply with age. The overlap found between dementia and depression may have nosological implications. There could be an effect of lower education levels on psychiatric morbidity, particularly on depression.

Psychiatric morbidity among medical out-patients in Spain: a case for new methods of classification.

A study was carried out to document the psychiatric disturbances among consecutive first-day attenders to an internal medicine out-patient clinic in Spain. Subjects were interviewed in three different stages using standardized procedures, basically the Clinical Interview Schedule (CIS). As hypothesized, the rate of disturbances was high (46.9%) and their classification with ICD-9 criteria was problematic. Minor affective disturbances were the most common diagnoses; the distribution of anxiety and depression scores followed the 'two correlated dimensions' model. The psychopathological differences between 'cases' and 'non-cases' seemed quantitative rather than qualitative. Absence of organicity, a pattern of multiple consultations and social problems were more frequent among the 'cases'. These data support the use of multiaxial classificatory systems. Ten supervised interviews significantly improved the internist recognition of 'cases' and the suggestion is made that a single routine question about the patients' mood would sensibly improve the detection rates.

[Revalidation and standardization of the cognition mini-exam (first Spanish version of the Mini-Mental Status Examination) in the general geriatric population]. / Revalidación y normalización del Mini-Examen Cognoscitivo (primera versión en castellano del Mini-Mental Status Examination) en la población general geriátrica.

BACKGROUND: The revalidation of the Mini Examen Cognoscitivo (MEC), first Spanish version (1978) of the Mini-Mental Status Examination (MMSE) and documentation of "population-based norms" should clarify the potential confusion induced by later versions of MMSE. CONTEXT: The Zaragoza Study on the prevalence of dementia and depression in a representative sample of the elderly community (N = 1,080). INSTRUMENTS: MEC-35 and MEC-30 points, and validated, Spanish versions of Geriatric Mental State (GMS), History and Aetiology Schedule (HAS) and Social Status Schedule (SSS). PROCEDURE: a) validation of MEC (standardized lay interviewers) against the gold standard of psychiatric diagnosis (DSM-III-R), two months later; b) "population-based norms" in the "healthy" population, and c) comparison with other MMSE versions. RESULTS: The instrument fulfills criteria of "feasibility", "content", "procedural" and "construct validity". Test-retest reliability: weighted kappa = 0.637. MEC-30 (cut-off point 23/24), sensitivity = 89.8%, specificity = 75.1% (80.8% with the cut-off at 22/23), and ROC curve, AUC = 0.920. The coefficients of individual items were satisfactory and the specificity increases in MEC-35 (83.9%). Other MMSE Spanish versions have not improved these coefficients. "Population-based norms" confirm the hypothesized influence of age and education level. MEC-30 is the version with most comparable results with the MMSE in USA. CONCLUSIONS: The validity of MEC is confirmed in the elderly population, with the same cut-off points recommended in the original standardization. MEC-30 is the best version for international comparisons.

Prevalence of dementia in a southern European population in two different time periods: the ZARADEMP Project.

OBJECTIVE: To compare the prevalence of dementia in two different time periods and two different studies. METHOD: Representative, random samples of the elderly (>65 years) in the Zaragoza Study or ZARADEMP-0 (n = 1080) completed the previous decade, and now in Wave I of the ZARADEMP Project or ZARADEMP-I (n = 3715) were interviewed. Standardized measures included the Geriatric Mental State and the History and Aetiology schedule. Cases of dementia were diagnosed according to DSM-IV criteria. RESULTS: Adjusted, global prevalence of dementia has not varied significantly: it was 5.2% (95% CI = 3.9-6.6) in ZARADEMP-0 and 3.9% (95% CI = 3.3-4.5) in ZARADEMP-I (prevalence ratio = 0.75; 95% CI = 0.56-1.02). However, the prevalence in ZARADEMP-I was significantly lower among men, particularly in all age groups between 70 and 84 years. CONCLUSION: Stability of the global prevalence of dementia in the elderly population has been documented. However, the decreased prevalence found in elderly men stimulated environmental hypotheses.

The AGECAT "organic" section as a screening instrument for minor cognitive deficits.

In the context of increasing concern in occidental countries about dementing diseases in the geriatric population, an epidemiological study has been done in the city of Zaragoza, Spain. The sample, randomly selected from the census, was stratified by age and sex and included 1,134 elderly (aged 65 plus years) living in the community. In phase I, lay interviewers administered the Spanish versions of the Geriatric Mental State (GMS) and Mini-Mental Status Examination to the elderly. The individuals were considered to be "probable cases" on the basis of GMS "global" scores previously reported to be valid. These "probable cases" were then examined in phase II by standardized psychiatrists using both, the GMS and MEC, but also the History and Aetiology Schedule (HAS). A proportion of "probable normals" were also examined by the psychiatrists to assess the validity of the screening procedure in the community. The identified "cases" of dementia and "cases" of depression were then studied by the neurologists in what we call phase III. Specific project criteria for dementia were used but, in fact, all identified "cases" of dementia fulfilled DSM-III criteria. Some data of the application of the AGECAT computer program in both, phase I and phase II are now reported. The different severity levels of cognitive deficits according to AGECAT criteria are compared with clinical criteria. The advantages and disadvantages of the computer program in the detection of minor cognitive difficulties are discussed.

The prevalence of dementia among elderly people living in Zaragoza and Liverpool.

The prevalence of dementia in elderly people living in the community was compared using data from Zaragoza (Spain) and Liverpool (UK). A standardized interview, the Geriatric Mental State (GMS), was administered to a random sample of 1070 persons in Liverpool and 1080 in Zaragoza. Using diagnoses derived from the GMS-AGECAT package we found no significant difference between the prevalence of dementia in Zaragoza (7.4%) and Liverpool (5.0%). The expected increase in prevalence with age was found, but the two cities did not appear to differ in the relationship between age and prevalence. No sex difference was apparent, and the two cities do not differ in the relationship between sex and prevalence.

Mortality and mental disorders in a Spanish elderly population.

OBJECTIVE: To analyse the relationship between mental disorders and mortality rates in the elderly community of Zaragoza, Spain. METHODS: Baseline, cross-sectional study (two-stage screening) of a representative, stratified sample (N=1080) of the elderly (65+ years) living in the community. Follow-up study (4.5 years). INSTRUMENTS: Spanish versions of Geriatric Mental State, AGECAT computerized diagnostic program and Mini-Mental Status Examination. RESULTS: Two hundred and sixteen subjects died during the follow-up period (global mortality rate 4.8% per year). Using a logistic regression model with sex, age, educational level, physical illness and AGECAT diagnoses as explanatory variables and alive/dead as response, the following odds ratios (95% confidence intervals in parentheses) were obtained (reference group: non-cases): 'subcases' 1.3 (0.9-2.0), 'organic' (dementia) 3.7 (2.0-6.7), global depression 3.0 (1.7-5.3), 'psychotic' depression (melancholic type) 3.7 (1.7-8. 4), 'neurotic' depression 2.7 (1.4-5.3) and 'neuroses' 0.8 (0.2-3.6). Both pure 'organic' and pure 'depressed' cases had higher mortality when compared with comorbidity cases. CONCLUSION: There is a significant association between psychiatric morbidity and mortality in the elderly living in a Spanish community. Mortality risk in psychiatric cases are higher than previously reported in the literature.