Pain in dementia: prevalence and associated factors: protocol of a multidisciplinary study.

BACKGROUND: Pain is a common problem in people with dementia, however the exact prevalence of pain in dementia subtypes, e.g. Alzheimer's Disease (AD), Vascular Dementia (VaD), Frontotemporal Dementia (FTD) and dementia with Lewy Bodies (DLB), is unknown, as is the relation between pain and the different subtypes of dementia. In this study, the prevalence of pain in people with dementia will be investigated per dementia subtype and the relationship between the various subtypes of dementia and the presence of specific types of pain (i.e. musculoskeletal pain, neuropathic pain and orofacial pain) will be examined. Secondly, associations between various types of pain, cognitive functioning, neuropsychiatric symptoms and quality of life in people with dementia will be examined. A third purpose is to study the value of the assessment of autonomic responses in assessing pain in people with dementia. Finally, the effect of feedback to the attending physician on the presence of pain, based on examination by investigators with backgrounds in neuropsychology, geriatric dentistry and elderly care medicine, will be evaluated. METHODS/DESIGN: A cross-sectional, partially longitudinal observational study in 400 participants with dementia, aged 60 years and older. Participants will be recruited from an outpatient memory clinic and dementia special care units. All participants will be examined by an elderly care medicine trainee, a dentist with experience in geriatric dentistry, and a neuropsychologist. The primary outcome is presence of pain. Secondary outcomes will include oral health, autonomic responses to pain stimulus, vital sensibility and gnostic sensibility, musculoskeletal examination, cognitive functioning, neuropsychiatric symptoms, and quality of life. DISCUSSION: This study will help to enhance our knowledge regarding the prevalence of different types of pain in different dementia subtypes i.e. AD, VaD, FTD and DLB. This study also aims to contribute to a better understanding of oral health status in people with dementia, the use of autonomic responses in the assessment of pain in people with dementia and the relationships between pain and cognitive symptoms, neuropsychiatric symptoms and quality of life in people with various dementia subtypes and in different stages of the disease.

Salivary cortisol as predictor for depression characteristics and remission in electroconvulsive therapy in older persons.

Objectives: Electroconvulsive therapy (ECT) is the most effective treatment for depression; however, consensus on predictors for ECT outcome is lacking. We aim to examine the relation between pre-ECT salivary cortisol values and clinical characteristics and ECT outcome in depressed, older persons.Methods: A total of 102 inpatients meeting DSM-IV criteria for depression and referred for ECT were selected. Salivary cortisol was assessed at five time points during the day, providing insight into the cortisol awakening curve to the ground (AUCg) and to the increase (AUCi) and evening cortisol level. Depression severity was assessed using the Montgomery-Asberg Depression Rating Scale (MADRS). Remission was defined as MADRS <10; response was defined as MADRS-reduction of at least 50%. Regression analysis was used to assess associations between cortisol and (1) clinical variables, including depression severity, psychomotor symptoms and presence of psychosis, and (2) ECT outcome.Results: No significant relations were found between AUCg, AUCi, evening cortisol and depression severity, psychomotor symptoms, and presence of psychosis. In addition, no significant relation was found between cortisol and response or remission.Conclusions: Our results do not support a relation between cortisol values and depression characteristics, or ECT outcome in severely depressed, older patients treated with ECT.

The influence of childhood abuse on cortisol levels and the cortisol awakening response in depressed and nondepressed older adults.

OBJECTIVES: Childhood abuse has been associated with depression in later life. This may be related to hypothalamic-pituitary-adrenal (HPA) axis functioning. Therefore we aimed to examine the impact of childhood abuse and its interaction with depression on cortisol levels in older adults. METHODS: Data from 418 participants (mean age 70.8 years) in the Netherlands Study of Depression in Older Persons (NESDO) were used; 187 participants experienced childhood abuse; 309 participants had a diagnosis of depression. Diurnal cortisol levels were determined using six saliva samples from every participant. Multiple regression analyses were performed. RESULTS: Significant negative associations between childhood abuse and morning cortisol levels were found. In nondepressed persons, both psychological and sexual abuse were associated with greater dynamics of the HPA axis in response to awakening. CONCLUSIONS: Childhood abuse is associated with lower basal cortisol levels at awakening irrespective of major depressive disorder (MDD). Higher reactivity of the HPA axis during the hour after awakening was found in nondepressed participants only, which might suggest that late-life depression modifies the effect of childhood abuse on the HPA axis. Older adults with a history of childhood abuse may be more negatively affected by stress or stressful events and this is reflected in dysregulation of the HPA axis.

Hypothalamus-Pituitary-Adrenal-axis activity and cognitive functioning in older adults.

Inconsistent results are found in the involvement of the Hypothalamus-Pituitary-Adrenal (HPA)-axis in cognitive functioning. This study examined the association between various saliva cortisol measures (the 1-h awakening cortisol, evening cortisol, diurnal change, and cortisol suppression) and cognitive functioning (episodic memory, processing speed, interference control, and working memory). Participants were older adults, between 60 and 93 years with (N = 328) and without (N = 119) a depressive disorder from the Netherlands Study of Depression in Older adults. No significant associations between cortisol and cognitive functioning were observed in the total sample. Only in non-depressed older adults, higher total cortisol secretion over the first hour after awakening and worse episodic memory, higher cortisol levels at awakening and better working memory, and higher diurnal change and better processing speed were significantly associated. Cortisol was not associated with cognitive functioning in depressed older adults. In older adults, the association between depression and cognitive functioning is likely the consequence of other biological or psychological mechanisms.

The predictive value of cortisol levels on 2-year course of depression in older persons.

BACKGROUND: Depressive disorders in older persons are associated with an altered functioning of the Hypothalamic-Pituitary-Adrenal (HPA)-axis. In adults, a lower cortisol awakening response is a predictor of a worse prognosis of depression, but to date longitudinal studies in older depressed persons are lacking. We hypothesised that a lower cortisol awakening response is also associated with poorer course of depression in later life. METHODS: Data were derived from the Netherlands Study of Depression in Older Persons (NESDO). Participants with a 6-month Major Depressive Disorder (MDD), who provided 2-year follow-up data, were included (n=246). Logistic regression analyses were conducted to examine the association between diurnal cortisol levels and depressive status at 2-year follow-up. RESULTS: Both lower (OR=3.54; 95% CI=1.59-7.89) and higher evening cortisol levels (OR=2.41; 95% CI=1.09-5.35) at baseline were associated with poorer prognosis of MDD. Low dexamethasone suppression was associated with poorer course (OR=2.37; 95% CI=1.09-5.16), but failed to reach significance after additional adjustment for severity and chronicity of MDD (OR=1.98; 95% CI=0.89-4.42). Cortisol awakening response was not significantly associated with course. Since smoking has a great impact on cortisol levels, we conducted post-hoc analyses including non-smokers only, indicating that lower evening cortisol levels (OR=2.83, 95% CI=1.31-6.13) predicted unfavourable course. CONCLUSIONS: This first longitudinal study on cortisol and prognosis of depression in older persons demonstrates that in particular lower evening cortisol levels may predict poorer course in MDD. This finding may have clinical implications. Evening cortisol values may serve as a marker to identify persons at risk for an unfavourable course.