Global cognitive trajectory patterns in Alzheimer's disease.

OBJECTIVES: The literature on Alzheimer's disease (AD) provides little data about long-term cognitive course trajectories. We identify global cognitive outcome trajectories and associated predictor variables that may inform clinical research and care. DESIGN: Data derived from the National Alzheimer's Coordinating Center (NACC) Uniform Data Set were used to examine the cognitive course of persons with possible or probable AD, a Mini-Mental State Examination (MMSE) of ≥10, and complete annual assessments for 5 years. SETTING: Thirty-six Alzheimer's Disease Research Centers. PARTICIPANTS: Four hundred and fourteen persons. MEASUREMENTS: We used a hybrid approach comprising qualitative analysis of MMSE trajectory graphs that were operationalized empirically and binary logistic regression analyses to assess 19 variables' associations with each trajectory. MMSE scores of ±3 points or greater were considered clinically meaningful. RESULTS: Five distinct cognitive trajectories were identified: fast decliners (32.6%), slow decliners (30.7%), zigzag stable (15.9%), stable (15.9%), and improvers (4.8%). The decliner groups had three subtypes: curvilinear, zigzag, and late decline. The fast decliners were associated with female gender, lower baseline MMSE scores, a shorter illness duration, or receiving a cognitive enhancer. An early MMSE decline of ≥3 points predicted a worse outcome. A higher rate of traumatic brain injury, the absence of an ApoE ϵ4 allele, and male gender were the strongest predictors of favorable outcomes. CONCLUSIONS: Our hybrid approach revealed five distinct cognitive trajectories and a variegated pattern within the decliners and stable/improvers that was more consistent with real-world clinical experience than prior statistically modeled studies. Future investigations need to determine the consistency of the distribution of these categories across settings.

Depression outcome among a biracial sample of depressed urban elders.

OBJECTIVES: There are a paucity of long-term studies from the United States concerning predictors of outcome among depressed older community adults. This article examines predictors of depression in a biracial sample of older persons in Brooklyn, NY. METHODS: The authors conducted a naturalistic study of 110 persons aged 55 years and older living in randomly selected block groups who had a Center for Epidemiologic Studies-Depression (CES-D) score of > or = 8 at baseline. Persons were reassessed on an average of 3 years later. Their mean age was 69 years, 52% were women, and 35% were whites, and 65% were blacks, among whom 71% were African Caribbeans. Using George's Social Antecedent Model of Depression, the authors examined the impact of 13 predictor variables on two outcome measures: presence of either subsyndromal or syndromal depression (CES-D score > or = 8) and presence of syndromal depression (CES-D score > or = 16). To control for design effects, the authors used SUDAAN for the data analysis. RESULTS: On follow-up, 82% and 88% of subsyndromally and syndromally depressed persons at baseline, respectively, were depressed (CES-D > or = 8). In logistic regression, baseline depressive symptoms, baseline anxiety symptoms, greater increase in anxiety symptoms during the follow-up period, and higher locus of control were predictors of any level of depression. These four variables along with greater paranoid ideation and/or psychoses and more reliable social contacts were significant predictors of syndromal depression on follow-up. There were no inter- or intraracial differences in outcome. CONCLUSION: Depressed community elders in Brooklyn have highly unfavorable outcomes. Preventive strategies that target at-risk persons-i.e., especially those with baseline subsyndromal depression, greater anxiety symptoms, and more paranoid ideation and/or psychoses-may reduce the development of severe or persistent depression.

Exploring potential pathways between parity and tooth loss among American women.

OBJECTIVES: We assessed the impact of parity on tooth loss among American women and examined mediators of this relationship. METHODS: The study sample comprised 2635 White and Black non-Hispanic women who had taken part in the third National Health and Nutrition Examination Survey. We examined the relationship between parity and tooth loss, by age and by socioeconomic position, and tested a theoretical model focusing on direct and indirect influences of parity on dental disease. Robust regression techniques were used to generate path coefficients. RESULTS: Although parity was associated with tooth loss, the relationship was not moderated through dental care, psychosocial factors, or dental health-damaging behaviors. CONCLUSIONS: Parity is related to tooth loss among American women, but the mechanisms of the association remain undefined. Further investigation is warranted to determine whether disparities in dental health among women who have been pregnant are caused by differences in parity or to physiological and societal changes (e.g., factors related to pregnant women's access to care) paralleling reproductive choices.

Racial differences in suicidality in an older urban population.

PURPOSE: This study used epidemiological data of older African Americans and Caucasians living in an urban community to compare those factors associated with active or passive suicidal ideation in each racial group. DESIGN AND METHODS: Using 1990 census data for Brooklyn, New York, we attempted to interview all cognitively intact adults aged 55 or older in randomly selected block groups. The sample consisted of 214 Whites and 860 Blacks. We adapted George's social antecedent model to examine 19 independent variables; the dependent variable was based on lifetime history of passive or active suicidal ideation (hereafter, suicidality). We weighted the sample by race and gender. To control for sampling design effects, we used SUDAAN for data analysis. RESULTS: Whites reported higher prevalence than Blacks for current suicidality (5.8% vs 2.3%) and lifetime suicidality (14.8% vs 10.2%). None of the differences were significant. In logistic regression analysis conducted for each race, four variables were associated with suicidality within both races: higher depressive symptom scores, higher anxiety symptom scores, copes by using medications, and lower religiosity. Two variables were associated with suicidality only among Whites: higher use of spiritualists and copes by keeping calm. One variable, greater use of doctors for mental health problems, was significant only among Blacks. IMPLICATIONS: There were no racial differences in the prevalence of suicidality. Virtually all of the factors associated with suicidality are potentially ameliorable. Among both racial groups, suicidality is likely to be impacted by addressing depressive and anxiety symptoms and, when appropriate, by encouraging various coping strategies, especially religiosity.

The prevalence of anxiety and associated factors in a multiracial sample of older adults.

OBJECTIVE: Few multiracial epidemiological community-based studies of anxiety have been conducted with older adults. This study examined the prevalence of subsyndromal and syndromal anxiety and associated factors among older persons living in an urban area. METHODS: Persons aged 55 years and over (214 Caucasian and 860 black) living in Brooklyn, New York, between 1996 and 1999 were interviewed in randomly selected block groups. The researchers used an adaptation of George's social antecedent model to examine the association of 18 variables with anxiety. Syndromal anxiety was defined as a score of 50 or higher on the Anxiety Status Inventory Scale (ASIS). Subsyndromal anxiety was defined as an ASIS score under 50 and a positive response on three or more ASIS items, including at least one worry item. The sample was weighted by race and gender on the basis of 1990 census totals. RESULTS: The prevalence of syndromal and subsyndromal anxiety was 2.3 and 13.3 percent, respectively. With binary logistic regression analysis, persons rated as having syndromal anxiety differed from nonanxious individuals on ten of the 18 variables and persons with subsyndromal anxiety differed on seven. The anxiety groups differed from each other on three variables. In the past year, 23 and 12 percent of persons with syndromal and subsyndromal anxiety, respectively, reported seeking mental health assistance. CONCLUSIONS: About 14 percent of older adults have anxiety, and much of it is untreated. Anxious and nonanxious individuals have substantial differences in psychosocial and health-related variables. Older adults who have subsyndromal anxiety can be viewed as distinct from nonanxious older individuals.

The prevalence of phobia and its associated factors in a multiracial aging urban population.

OBJECTIVE: There have been few multiracial epidemiologic community-based studies of phobia in older adults. The aim of this study was to determine the prevalence of phobia and associated factors among older persons living in a northeastern urban area. METHODS: Using 1990 census data for Brooklyn, NY, the authors attempted to interview all persons age 55+ in randomly selected block groups. The final sample consisted of 214 whites and 860 blacks. The authors used an adaptation of George's Social Antecedent Model for examining the association of 18 individual variables and one interactive variable with the presence of a phobia. The dependent variable was derived from the Guy's/Age Concern community survey. The sample was weighted by race and gender. To control for design effects, the authors used SUDAAN for the data analysis. RESULTS: A total of 8.9% of the sample met criteria for a current phobia and 10.2% met phobia criteria at some time during their life. Using logistic regression analysis, the authors found six variables-higher personal income, more depressive symptoms, poorer physical health, use of prayer as a coping strategy, use of spiritualists or their products, and not having been raised by both parents-to be significantly associated with a current phobia. CONCLUSION: The prevalence rate of phobia was comparable to rates for older adults in the urban areas of the Epidemiologic Catchment Area study suggesting that prevalence has remained stable over the past two decades. Consistent with earlier studies, there were significant associations among phobia, depressive symptoms, and physical illness. Many of the demographic and social variables, including race, that had been reported previously to be associated with phobias in younger samples were not significant in this study.

Racial differences in syndromal and subsyndromal depression in an older urban population.

OBJECTIVE: The authors explored racial differences in the prevalence of depression and its associated factors among older persons. METHODS: Using 1990 census data for Brooklyn, New York, the authors attempted to interview all cognitively intact persons age 55 years and older in randomly selected block groups. The sample was weighted by ethnicity and gender. The authors adapted George's Social Antecedent Model of Depression to allow examination of 20 independent variables and the nominal dependent variable consisting of three levels of depression. The data were analyzed with SUDAAN. RESULTS: Syndromal depression was found among 8 percent of blacks and 10 percent of whites. Subsyndromal depression was found among 13 percent of blacks and 28 percent of whites. No racial differences were found in rates of syndromal depression, but significant racial differences were found in rates of subsyndromal depression and of any type of depression. Nonlinear effects on both types of depression were found, and higher levels of stress had a greater impact on whites than on blacks. The racial difference in subsyndromal depression was explained by its lower prevalence among French-speaking African Caribbeans. Many racial differences were found in the variables associated with syndromal and subsyndromal depression. CONCLUSIONS: Race had an independent effect on the rate of subsyndromal depression and an interactive effect with stress on the rate of both syndromal and subsyndromal depression. For each racial group, different elements may play a role in the etiology, maintenance, and relief of depression. The findings underscore the importance of recognizing within-group and between-group racial differences in depression.

Comparison of users and non-users of mental health services among depressed, older, urban African Americans.

OBJECTIVE: The authors sought to determine differences between depressed older black residents in an urban community who do and do not use formal mental health services. METHODS: The Treatment Group (TG) consisted of 106 black patients age >or=55 with a diagnosis of depression who were recruited from outpatient psychiatric programs in Brooklyn, NY. The Untreated Community Group (UCG) consisted of 101 cognitively intact black subjects age >or=55 from randomly selected block groups in Brooklyn who met symptom criteria for major or minor depression and had no previous history of psychiatric treatment. RESULTS: In logistic regression analysis, TG persons were significantly more likely than the UCG persons to be female, younger, born in the United States, to have impaired daily functioning, have a family history of mental illness, and believe that environmental factors and religious activities could influence mental illness. TG persons were significantly less likely to have social network members who provided advice, to use spiritualists or their products, to have vision or hearing impairments, and to have depressive symptoms. Although most UCG persons visited their doctor at least three times annually, only 11% reported using these physicians for help with mental health problems. CONCLUSIONS: A combination of demographic and attitudinal factors, family psychiatric history, social supports, and functional impairments were associated with the use of mental health services. Despite reluctance of persons in the UCG to use primary-care physicians for mental health reasons, the latter remain the most feasible intervention point within the existing service system.

Ultrasensitive serum prostate specific antigen nadir accurately predicts the risk of early relapse after radical prostatectomy.

PURPOSE: Ultrasensitive prostate specific antigen (PSA) assays allow a lower limit of detection (less than 0.01 ng/ml) than standard PSA assays. In this study we examined the ability of ultrasensitive PSA nadir to predict relapse after radical prostatectomy (RP). MATERIALS AND METHODS: A total of 906 men treated with RP were followed with PSA measurements at 3, 6 and 12 months, and yearly thereafter. Of the 906 men 545 (60%) with a PSA nadir of less than 0.01 ng/ml or at least 3 followup ultrasensitive PSA measurements underwent analysis and stratification by PSA nadir. Biochemical relapse was defined as 2 consecutive increasing post-nadir PSA measurements of 0.1 ng/ml or greater. The ability of ultrasensitive PSA nadir to predict relapse was assessed by univariate and multivariate analysis. RESULTS: At a mean followup of 3.1 years 54 of 545 men (9.9%) experienced biochemical relapse with a mean time to relapse of 25.2 months. Relapse rates in men with a PSA nadir of less than 0.01 (423), 0.01 (75), 0.02 (19) and 0.04 or greater ng/ml (28) were 4%, 12%, 16% and 89%, respectively. Men with a nadir of less than 0.01 ng/ml had a significantly lower relapse rate than men with a nadir of 0.01 (p <0.01), 0.02 (p <0.025) or 0.04 or greater ng/ml (p <0.01). Multivariate logistic regression analysis showed that a nadir of 0.01 (p <0.05), 0.02 (p <0.05) and 0.04 or greater ng/ml (p <0.01) independently predicted an increased risk of biochemical relapse compared to a nadir of less than 0.01 ng/ml. CONCLUSIONS: Ultrasensitive PSA nadir accurately predicts the risk of early biochemical relapse following RP. Men who achieve a nadir of less than 0.01 ng/ml have a low likelihood of early relapse. Higher nadir points may identify candidates for early adjuvant or salvage therapies.

Racial differences in paranoid ideation and psychoses in an older urban population.

OBJECTIVE: This study examined whether there are racial differences in the prevalence of paranoid ideation and psychotic symptoms in persons age >/=55 in an urban community. METHOD: Using 1990 census data for Brooklyn, N.Y., the authors attempted to interview all cognitively intact persons age >/=55 in randomly selected blocks. The final group consisted of 206 whites and 821 blacks. The authors used George's Social Antecedent Model for analyzing 21 independent and three dependent variables: paranoid ideation, psychotic symptoms, and psychotic symptoms/paranoid ideation. The group was weighted by race and gender. To control for intrablock clustering effects without replacement sampling, the authors used SUDAAN for data analysis. RESULTS: A significant difference in psychotic symptoms or paranoid ideation was found between blacks and whites (24% versus 10%) that was attenuated but not eliminated with logistic regression analyses. Blacks with psychotic symptoms or paranoid ideation, especially Caribbeans, had significantly lower receipt of mental health services and lower perceived service needs. With logistic regression, psychotic symptoms and paranoid ideation were associated with four variables among blacks and whites, although only one was significant in both groups. CONCLUSIONS: Racial differences in psychotic symptoms and paranoid ideation persist even after control for various clinical, social, and attitudinal effects. Among blacks, response to stressors may be expressed through increased paranoid ideation and psychotic symptoms. Stronger beliefs in spiritualism increase this expression in both races. The high prevalence of psychotic symptoms or paranoid ideation among this aging urban population, especially blacks, highlights a potential public health issue.