Prevalence of depression and its treatment in an elderly population: the Cache County study.

BACKGROUND: Previous estimates of the prevalence of geriatric depression have varied. There are few large population-based studies; most of these focused on individuals younger than 80 years. No US studies have been published since the advent of the newer antidepressant agents. METHODS: In 1995 through 1996, as part of a large population study, we examined the current and lifetime prevalence of depressive disorders in 4,559 nondemented individuals aged 65 to 100 years. This sample represented 90% of the elderly population of Cache County, Utah. Using a modified version of the Diagnostic Interview Schedule, we ascertained past and present DSM-IV major depression, dysthymia, and subclinical depressive disorders. Medication use was determined through a structured interview and a "medicine chest inventory." RESULTS: Point prevalence of major depression was estimated at 4.4% in women and 2.7% in men (P= .003). Other depressive syndromes were surprisingly uncommon (combined point prevalence, 1.6%). Among subjects with current major depression, 35.7% were taking an antidepressant (mostly selective serotonin reuptake inhibitors) and 27.4% a sedative/hypnotic. The current prevalence of major depression did not change appreciably with age. Estimated lifetime prevalence of major depression was 20.4% in women and 9.6% in men (P<.001), decreasing with age. CONCLUSIONS: These estimates for prevalence of major depression are higher than those reported previously in North American studies. Treatment with antidepressants was more common than reported previously, but was still lacking in most individuals with major depression. The prevalence of subsyndromal depressive symptoms was low, possibly because of unusual characteristics of the population.

Dementia diagnoses from clinical and neuropsychological data compared: the Cache County study.

OBJECTIVE: To validate a neuropsychological algorithm for dementia diagnosis. METHODS: We developed a neuropsychological algorithm in a sample of 1,023 elderly residents of Cache County, UT. We compared algorithmic and clinical dementia diagnoses both based on DSM-III-R criteria. The algorithm diagnosed dementia when there was impairment in memory and at least one other cognitive domain. We also tested a variant of the algorithm that incorporated functional measures that were based on structured informant reports. RESULTS: Of 1,023 participants, 87% could be classified by the basic algorithm, 94% when functional measures were considered. There was good concordance between basic psychometric and clinical diagnoses (79% agreement, kappa = 0.57). This improved after incorporating functional measures (90% agreement, kappa = 0.76). CONCLUSIONS: Neuropsychological algorithms may reasonably classify individuals on dementia status across a range of severity levels and ages and may provide a useful adjunct to clinical diagnoses in population studies.

Telephone adaptation of the Modified Mini-Mental State Exam (3MS). The Cache County Study.

OBJECTIVE: To examine the concurrent validity of a newly developed telephone adaptation of the Modified Mini-Mental State Exam. BACKGROUND: Longitudinal studies of cognition may be advantaged by availability of assessment instruments that can be used over the telephone, as well as in person. METHOD: Subjects were 263 noninstitutionalized elderly residents of a rural community in southern Idaho, aged 65 to 93, who had little or no cognitive difficulty. At an average interval of four weeks, we administered the Modified Mini-Mental State Exam (3MS) and the newly adapted Telephone Modified Mini-Mental State Exam (T3MS). Order of administration was randomly assigned. RESULTS: Agreement between scores on the two instruments was good (r = 0.82, p < 0.001). When we applied various cutoff scores to the instruments, thereby generating assignments of individuals to "screen positive" and "screen negative" groups, the percent agreement in screening results ranged from 80% to 96% as we reduced the cutoff scores from 90 to 74 (100 points possible). CONCLUSIONS: At least among subjects without major cognitive syndromes, the Telephone Modified Mini-Mental State Exam provides a reasonable substitute for the more costly in-person 3MS. The telephone instrument should now be tested over a broader range of cognitive abilities in order to assess its validity in more impaired subjects, e.g., by studying an institutionalized sample.

Enhanced cognitive performance with estrogen use in nondemented community-dwelling older women.

OBJECTIVE: To examine the association between history of postmenopausal estrogen use and cognitive function in a large sample of nondemented community-dwelling older women. SETTING: A community of older residents in Cache County, Utah. PARTICIPANTS: A total of 2338 nondemented women aged 65 and older. MEASUREMENTS: All subjects were administered the Modified Mini-Mental State Examination (3MSE). Self-reported information on current and past use of estrogen after menopause was also obtained using a structured interview. Estrogen use was trichotomized as: no use, past use, and current use. Apolipoprotein E (APOE) genotype was determined and was dichotomized by the presence of an epsilon4 allele. A series of variance/covariance models was conducted with the 3MSE score as the dependent variable, first considering estrogen use alone, then adding, sequentially as covariates, education, age, health status, APOE genotype, current depression status, and history of head injury. RESULTS: In the simplest bivariate model, the 3MSE means (and confidence intervals) were 92.1 (91.7-92.4), 93.5 (93.1-93.9), and 94.4 (94.0-94.7) for never-, past-, and current users, respectively. In the final model (R2 = 0.28), no use of estrogen replacement therapy (P = .006), lower education (P < .001), poorer perceived health status (P = .035), current depression (P = .014), and presence of at least one APOE epsilon4 allele (P < .001) each independently predicted lower 3MSE score. Both current and past estrogen users had significantly higher 3MSE scores than never-users (P = .0063 and P = .0096, respectively). CONCLUSIONS: In this large community study, women who had used estrogen after menopause scored higher on the 3MSE. This finding remained, even after controlling for the effects of age, education, APOE genotype, and other variables that may affect cognition. These data support studies reporting a beneficial role of estrogen on cognition in postmenopausal women, particularly among current estrogen users.

APOE-epsilon4 count predicts age when prevalence of AD increases, then declines: the Cache County Study.

OBJECTIVE: To examine the prevalence of Alzheimer's disease (AD) and other dementias in relation to age, education, sex, and genotype at APOE. Recent studies suggest age heterogeneity in the risk of AD associated with the APOE genotype and a possible interaction between APOE-epsilon4 and female sex as risk factors. We studied these topics in the 5,677 elderly residents of Cache County, Utah, a population known for long life expectancy and high participation rates. METHODS: We screened for dementia with a brief cognitive test and structured telephone Dementia Questionnaire, then examined all individuals with apparent cognitive symptoms and a sample of others. We estimated age-specific prevalence of AD and other dementias and used multiple logistic regression models to describe relation of AD prevalence to age, sex, education, and APOE genotype. RESULTS: We found 335 demented individuals, 230 (69%) with definite, probable, or possible AD (positive predictive value versus autopsy confirmation 85%). The adjusted prevalence estimate for AD was 6.5% and for all dementias 9.6%. After age 90, the adjusted prevalence estimate for AD was 28% and for all dementias 38%. Regression models showed strong variation in AD prevalence with age, sex, education, and number of epsilon4 alleles (effect of epsilon2 not significant). Models were improved by a term for age-squared (negative coefficient) and by separate terms for interaction of age with presence of one or two epsilon4 alleles. An association of AD with female sex was ascribable entirely to individuals with epsilon4. CONCLUSIONS: In participants with no epsilon4 alleles, the age-specific prevalence of AD reached a maximum and then declined after age 95. In epsilon4 heterozygotes a similar maximum was noted earlier at age 87, in homozygotes at age 73. Female sex was a risk factor for AD only in those with epsilon4. The epsilon4 allele accounted for 70% of the population attributable risk for AD.

Characteristics of nonresponders in a community survey of the elderly.

OBJECTIVE: To identify predictors of nonresponse in a community survey of cognitive status in the elderly. DESIGN: Cross-sectional community survey with two stages of recruitment: an initial, less-intensive method, followed by a more aggressive approach that included face-to-face contact. Characteristics of initial nonresponders and responders were compared. SETTING: A close-knit rural community with higher than usual proportions of elderly, especially the very old. Subjects were interviewed in their homes. Collateral informants were subsequently interviewed by telephone. PARTICIPANTS: Utah heads of household aged 75 and older who resided in a noninstitutionalized setting. MEASUREMENTS: Mini-Mental State Examination (MMSE), Dementia Questionnaire, and an autobiographical risk factor and family history questionnaire provided measures for all independent variables. The dependent variable was status as initial responders or initial nonresponders. RESULTS: An initial participation rate of 63% was achieved, but a final rate of 93% was achieved when initial nonresponders were contacted later face-to-face. MMSE score was significantly related to responder status when analyzed alone (beta = -.19, P = 0.02) and remained a significant predictor after adjusting for education and whether born in Cache County (beta = -.16, P = 0.041) or current drinking, diabetes, or "other" health problems (beta = -.18, P = 0.028). After controlling for the informant report of subject's problems with activities of daily living, MMSE score fell just below statistical significance (beta = -.16, P = 0.079). CONCLUSIONS: Nonresponders in community surveys of the elderly appear to be disproportionately cognitively impaired. The increase in participation rates achieved after more persistent recruitment suggests that many initial nonresponders can still be recruited if intensive methods are used.

Nutrition labels in bar graph format deemed most useful for consumer purchase decisions using adaptive conjoint analysis.

This study estimated the effects of changing multiple levels and combinations of nutrition information format, load, expression, and order on consumers' perceptions of label usefulness in purchase decisions using adaptive conjoint analysis. A shopping mall intercept survey, which was administered by a marketing research firm, assessed consumer preferences for 12 label alternatives produced on Campbell's soup cans to portray nutrition information realistically; 252 of 258 respondents completed the computer interactive interview. Consumers significantly preferred the bar graph format to the bar graph/nutrient density and traditional label formats. Consumers considered the bar graph/nutrient density format to be as useful as the traditional label format. There was a highly significant difference among the three levels of information load; the most information load was preferred regardless of nutrient importance. Consumers significantly preferred nutrition information stated in absolute numbers and percentages vs in absolute numbers only in traditional, or in percentages only expressions. There was a significant difference between consumer preferences for the two types of information order. The findings indicate that consumers clearly preferred the nutrition label that displayed all nutrient values using a bar graph format, offered the most information load, and expressed nutrient values using both absolute numbers and percentages. Consumers also preferred nutrition information rearranged in an order that grouped nutrients that should be consumed in adequate amounts on the top, calories in the middle, and nutrients that should be consumed in lesser amounts on the bottom of the label.

Review of nutrition labeling formats.

This article examines nutrition labeling history as well as the findings of nine research studies of nutrition labeling formats. Nutrition labeling regulations were announced in 1973 and have been periodically amended since then. In response to requests from consumers and health care professionals for revision of the labeling system, the Food and Drug Administration initiated a three-phase plan for reform of nutrition labeling in 1990. President Bush signed the Nutrition Labeling and Education Act in November 1990. Literature analysis revealed that only nine studies with an experimental design have focused on nutrition labeling since 1971. Four were conducted before 1975, which was the year that nutrition labeling was officially implemented, two were conducted in 1980, and three were conducted after 1986. Only two of the nine studies supported the traditional label format mandated by the Code of Federal Regulations, and one study partially supported it. Four of the nine studies that evaluated graphic presentations of nutrition information found that consumer comprehension of nutrition information was improved with a graphic format for nutrition labeling: three studies supported the use of bar graphs and one study supported the use of a pie chart. Full disclosure (ie, complete nutrient and ingredient labeling) was preferred by consumers in two of the three studies that examined this variable. The third study supported three types of information disclosure dependent upon socioeconomic class. In those studies that tested graphics, a bar graph format was significantly preferred and showed better consumer comprehension than the traditional format.

Integrity of small data bases in computer analysis of dietary data.

The integrity of data bases to support microcomputer-based dietary analysis programs has become increasingly important to developers and users of nutritional analysis software. This paper reviews critical issues in maintaining data integrity during development of small nutritional data bases. Because a limited number of large, source data bases provides the data for smaller, special-purpose data bases, this review initially focuses on factors that affect the quality and precision of methodologies used in establishing large data bases. Issues discussed are accuracy of source data as determined by analytical methodology and imputation procedures, and methods for insuring representativeness of data. The effect of data transfer procedures on small data base integrity are discussed, including use of multiple sources and standardization of naming and coding conventions. Also reviewed are procedures for selecting reduced numbers of foods and nutrients without sacrificing accuracy of analysis, and methods currently in use for validating small data bases.

Enzymes for liberation of pantothenic acid in blood: use of plasma pantetheinase.

Reported normal concentrations for human whole-blood total pantothenic acid vary from 1.1 to 12 mumol/L. This wide range may partly arise from the various enzymes used for liberation of pantothenic acid from coenzyme A, particularly the source of pantetheinase. A purified pantetheinase from pig kidney had greater than 100 times the specific activity and less than 0.01 times the pantothenate content of other commonly used extracts. Endogenous pantetheinase activity in human plasma was identified (11.2 +/- 2.0 mumol pantothenate .min-1.L-1, n = 29) and found comparable to the activity usually added from exogenous sources for liberation of pantothenate from whole blood (1-13 mumol.min-1.L-1). Alkaline phosphatase alone liberated as much pantothenate from hemolyzed whole blood as did alkaline phosphatase with pantetheinase. Previous reports of total blood pantothenate may be elevated by pantothenate in the pantetheinase extracts, an unnecessary source of error. Whole-blood total pantothenate concentrations less than 4.6 mumol/L are normal and do not indicate deficiency, as is often currently quoted.

Pantethine lipomodulation: evidence for cysteamine mediation in vitro and in vivo.

Recent human studies suggest rapid in vivo hydrolysis of the lipid-lowering drug, pantethine, to the vitamin pantothenic acid and the small aminothiol compound, cysteamine. To test whether the active agent is a hydrolysis product, we repeated three experimental models of pantethine's effect with pantothenate and cysteamine. In vitro experiments with human fetal fibroblasts showed equivalent modulation of cholesterol and methyl sterol synthesis by pantethine, cysteamine, or cystamine (the disulfide of cysteamine), but pantothenate had no effect. Similarly, in vivo experiments with 0.5% cholesterol-fed rabbits showed oral pantethine or equimolar cystamine significantly lowered plasma cholesterol, while pantothenate, cystine, and 2-hydroxyethyl disulfide did not. Lastly, diabetic male rats (40 mg/kg streptozotocin) fed 0.1% pantethine and lower plasma free fatty acids after 2 weeks than controls, an effect not seen with pantothenate and largely duplicated by cystamine. The efficacy of pantethine has previously been attributed to altered vitamin metabolism and increased coenzyme A concentration. Pantethine did increase CoA levels 45% in rat liver homogenates while equivalent amounts of cystamine or pantothenate did not. However, a causal relationship between CoA levels and pantethine's action as a hypolipemic agent has never been shown. At least in 3 independent experimental models, the lipomodulating effect of pantethine appears instead to be mediated by the hydrolysis product cysteamine.

Using videodisc technology and the Index of Nutritional Quality to teach dietary guidance to young adults.

A review of the literature indicated a need for nutrition education materials to be current with prevailing scientific knowledge, using advanced instructional technology. Individuals need help in applying nutrition principles to their dietary practices. A nutrition education program utilizing the nutrient density concept and the dietary guidelines for use on videodisc with microcomputer interface was developed and evaluated. The evaluation of the program did not prove to be statistically effective, but learners did show an interest in the program and had positive feedback in regard to the information presented and the technology used.

Pantothenic acid status of adolescents.

Information on human needs for pantothenic acid is limited and no recommended daily allowance has been established, although a safe and adequate level of 4-7 mg/day has been suggested for adults and adolescents. Pantothenic acid levels in urine, whole blood, and erythrocytes were determined by radioimmunoassay in 63 healthy adolescents. Dietary intakes were calculated and evaluated from 4-day diet records. Although 49% of the females and 15% of the males consumed less than 4 mg/day, average blood levels for both groups were in a normal range relative to other populations (411.9 +/- 102.8 ng/mL and 344.5 +/- 113.6 ng/mL, respectively). Dietary intake was highly correlated with urinary excretion (p less than 0.001). Levels of pantothenic acid in erythrocytes correlated well with dietary intake and urinary excretion. A model was developed to predict circulating levels of pantothenic acid from dietary intake and urinary excretion.

Cluster analysis to improve food classification within commodity groups.

Mathematical clustering algorithms were used to classify foods within dairy, grain, and fat commodity groups on the basis of nutrients with limited availability in the food supply as well as those posing a possible health risk due to excess consumption. The procedure overcomes the problem that has made objective and accurate grouping, i.e., dealing simultaneously with 10 or more nutrients, difficult. The clustering routine classifies foods on the basis of similar nutrient content for any number of food attributes and assigns a degree of association to each food to indicate its compositional similarity to a prototype food for the cluster group. Foods within dairy, grain, and fat commodity groups were clustered on the basis of similar content of vitamin B-6, calcium, iron, magnesium, folacin, zinc, and added sugar, fat, cholesterol, and sodium. Whole milk and natural cheese clustered together on the basis of their moderate nutrient and relatively high fat and sodium content. Whole wheat breads, pumpernickel bread, and pancakes from mix constituted a grain subgroup with highest nutrient content, lowest cholesterol and sugar, lower fat, and higher sodium. Other subgroups based upon similarities in attributes were identified within food commodity categories. The result is an expansion of some food groups to incorporate concepts of both nutritional adequacy and moderation of food components of current nutritional concern.

Nutrition intervention: panacea or Pandora's box?

Past intervention efforts have not been effective in solving the nutrition problems in either industrialized or developing nations. While it may be intellectually stimulating, arguing over the subtleties of various strategies does not serve to improve the nutritional well-being of populations and may actually be detrimental. Whether we are concerned about an excess of calories or an inadequate supply of calories, the issue of calories is critical worldwide. A nutrient density approach provides a unified, scientifically justifiable, comprehensive approach to improving the nutritional status of populations in both developed and developing countries.

Pantothenic acid status of pregnant and lactating women.

Pantothenic acid nutritional status was evaluated longitudinally in 26 pregnant women (experimental group) during their third trimester of pregnancy and at 2 weeks and 3 months postpartum. Seventeen nonpregnant and nonlactating women (control group) participated at the same time intervals. All the women were assessed by the intake calculated from a reported 2-day dietary record and by fasted blood, plasma, and 24-hour urinary levels of pantothenate determined by a radioimmunoassay. Estimated daily mean dietary pantothenate intake and the vitamin density for the experimental group were not statistically different from those for the control group. The dietary pantothenate intake averaged 2.75 mg/1,000 kcal. Average pantothenate blood level of the experimental group was lower than that of the control group. No significant difference was found between the two groups in the pantothenate levels of fasting plasma and urinary excretion. When they did not take pantothenic acid supplements, members of the experimental group had intakes less than the Estimated Safe and Adequate Daily Dietary Intake and lower mean blood values than the members of the control group. This suggests that pregnant and lactating women need to consume more pantothenate to maintain a blood vitamin level similar to that of nonpregnant women. This may be achieved by an increased caloric intake, if desirable, or by more careful selection of foods high in the nutrient.

Effect of pantothenic acid status on the content of the vitamin in human milk.

Seventeen lactating women who delivered preterm infants (between 28 to 34 wk of gestational age) and 26 nursing mothers of term infants participated in the study. Each term mother kept a record of 2-day dietary intakes, collected urines for 2 days, and provided fore and hind milk samples and a fasting blood sample at 2 and 12 wk postpartum. Each of preterm women provided fore and hind milk samples once a week for 16 wk starting 2 wk postpartum. The method of determining pantothenic acid content in milk samples was validated, and the vitamin was quantitated by the radioimmunoassay. The average pantothenate levels in fore and hind samples of preterm milk (3.31 and 3.72 micrograms/ml, respectively) were significantly (p less than 0.05) higher than those of term milk (2.64 and 2.48 micrograms/ml, respectively). No significant change was observed in pantothenic acid content within a feeding or with the progress of nursing in both groups. The vitamin content of human milk was compared with the minimum requirement of the Infant Formula Act of 1980. The pantothenate level in term milk was significantly (p less than 0.05) correlated with the vitamin level in maternal circulation and with that of the dietary intake and urinary excretion.