Head injuries and cognitive decline among older adults: a population-based study.

OBJECTIVE: To examine the relationship between minor and major head injuries caused by fall accidents and cognitive decline among a cohort of adults age 70 years or older (n = 588). BACKGROUND: Even a mild brain injury may affect cognitive functions. Among older adults, results from case-control studies suggest that the occurrence of head injury is positively associated with the onset of AD. METHODS: The shortened version of the Mini-Mental State Examination (sMMSE) was performed and a set of demographic and clinical variables were collected at the beginning of the study. All falls were recorded during a period of 2.5 years, after which the sMMSE tests were repeated. The risk of falls causing head injury in terms of a defined cognitive decline was examined during another follow-up period of approximately 2.5 years. RESULTS: There was no association between the occurrence of minor head injuries and decline in sMMSE scores. A positive relationship existed between the occurrence of major head injuries and a decline in sMMSE scores. The risk of cognitive decline increased linearly as higher cut-off points were used to define the decline in sMMSE scores-with relative risks (95% CI) of 0.94 (0.47 to 1.90), 1.35 (0.64 to 2.85), 1.75 (0.78 to 3.91), 2.38 (1.02 to 5.52), and 3.72 (1.64 to 8.44)-for a decline of > or =1, > or =2, > or =3, > or =4, and > or =5 points in the sMMSE score. The high risk remained unchanged after adjustment for other potential factors contributing to cognitive decline or dementia. The risk factors associated with falls causing major head injury during the second follow-up period were high age, OR (95% CI) 3.58 (1.87 to 6.85); use of psychotropic medication, 2.04 (1.09 to 3.83); diagnosis of hypertension, 1.80 (0.96 to 3.37); and decline in sMMSE score of >5 points, 2.41 (0.86 to 6.76). CONCLUSIONS: Our results suggest that the occurrence of major head injury increases the risk of cognitive decline. The cause of cognitive decline may be dementia, but this assumption remains to be elucidated in future studies.

APOE epsilon4 does not predict mortality, cognitive decline, or dementia in the oldest old.

OBJECTIVE: To examine the effect of the epsilon 4 allele on cognitive decline in the oldest old. METHODS: We studied all 601 citizens of the city of Vantaa age 85 years and older in 1991. A total of 553 subjects (92%) took part in the study, which used the Mini-Mental State Examination (MMSE) and assessment of dementia according to the Diagnostic and Statistical Manual of Mental Disorders, third ed., revised (DSM-III-R) criteria. The survivors were re-examined 3 years later. APOE genotype was determined in 510 subjects, representing 83.2% of the original population. RESULTS: Approximately one-half of the subjects (n = 250) died before the follow-up, and 253 subjects (97.3% of the survivors) were re-examined. The occurrence of the APOE epsilon 4 allele did not have any significant effect on survival. Of the 187 previously nondemented subjects, 58 (31%) had developed dementia. The OR for the epsilon 4 carriers to develop dementia was not significant: OR = 1.78; 95% CI = 0.88 to 3.60. In individuals with a follow-up MMSE score (n = 222), the mean decline in the score was 3.1 points. APOE epsilon 4 carrier status did not have a significant effect on the mean MMSE change except in the previously demented subjects, among whom the drop was larger in the APOE epsilon 4 carriers. CONCLUSIONS: The lack of association between APOE epsilon 4 carrier status and mortality, or development of dementia, or cognitive decline in these very elderly people, whether analyzed in the whole population or among the nondemented subjects only, suggests that the APOE epsilon 4 effect in younger subjects is age-dependent, and that it is no longer present in very old age.

Orthostatic hypotension and cognitive decline in older people.

OBJECTIVES: To establish the role of orthostatic hypotension (OH) as a risk factor for cognitive decline among home-dwelling and institutionalized older people and to describe other predictors of cognitive decline. DESIGN: Follow-up study with two clinical examinations. SETTING: A community-based setting in northern Finland. PARTICIPANTS: All of the 1159 people aged 70 or more living in five rural municipalities around the town of Oulu in Northern Finland in 1991. At the time of the follow-up examination, 2.5 years later, 884 of the original participants were alive and 651 were re-examined. MEASUREMENTS: In 1991, 907 people (78.3% of the total population) were tested for orthostatic hypotension, and their cognitive capacity was assessed with the Mini-Mental State Examination (MMSE). The calculation/spelling tasks were excluded from the final version used in the statistical analysis. The re-assessment of cognitive capacity was made on 651 subjects (73.6% of those alive) who had participated in the first examination. The data were analyzed using polychotomous and linear regression analysis models. RESULTS: The prevalence of OH was 28.7%, with no age or sex differences. The mean sum score for the shortened MMSE in 1991 was 21.6 (+/-3.98) for persons with OH and 21.1 (+/-4.08) for non-OH persons. During the follow-up, the sum score declined in the OH group by .44 (+/-2.81) points and in the non-OH group by .83 (+/-3.61) points. No type of OH (systolic or diastolic 1- or 3-minute values or their combination) predicted cognitive decline; the only predictors were old age and low level of formal education. CONCLUSIONS: Orthostatic hypotension is a common clinical condition that affects every fourth person aged 70 years or older. By temporarily inducing cerebral hypoperfusion, it may cause or exacerbate cognitive dysfunction. In an unselected population, OH was not associated with cognitive deterioration, nor did it predict cognitive decline during a 2-year follow-up.

Marital and family relations and depression in married elderly Finns.

BACKGROUND: The aim was to describe the relationships between poor marital and family relations and depression, and the predictive value of these factors for the subsequent occurrence of depression. METHODS: The population for the cross-sectional study consisted of the married elderly (N = 498) living in Ahtäri, Finland, in 1989. The series of the longitudinal study was composed of married persons nondepressed in the epidemiological study in 1984-1985, and followed up until 1989-1990 (N = 347). RESULTS: In men, impaired functional abilities (OR 5.0) and poor family relations (OR 2.9), and in women, impaired functional abilities (OR 3.9), family violence (OR 4.2), age 70 years or over (OR 3.0) and a loss of father in childhood or youth (OR 2.5) were independently related to depression. Poor marital relations tended to be related to depression in both men (OR 2.1) and women (OR 2.2). In both sexes, poor self-appreciation (OR men 3.9; women 7.1) and age 70 years or over (OR men 2.9; women 4.2), and in women, a loss of father in childhood or youth (OR 4.5) were independent predictors of subsequent depression. CONCLUSIONS: The poor marital or family relations experienced by many depressed elderly persons are usually consequences rather than predictors of depression. Family violence may be a consequence of depression or even a risk factor for depression. CLINICAL IMPLICATIONS: Problems in spouse pairs and families should be inquired and solved when treating depressed elderly persons. LIMITATIONS OF THE STUDY: Due to the unknown validity of the measure concerning marital relations, the results are suggestive.

Fall-related brain injuries and the risk of dementia in elderly people: a population-based study.

Severe head injury in early adulthood may increase the risk of dementia in older age, but it is not known whether head injury in later life also increases the risk of dementia. A representative sample (82%) of persons aged 70 years or older with a Mini-Mental State Examination (MMSE) test score of > or =26 (n = 325) were followed-up for 9 years to record all their fall-related head injuries resulting in traumatic brain injury (TBI). At the end of the follow-up period, 152 persons (81% of the surviving population) were examined for clinical dementia, according to DSM-IV criteria. Eight persons sustained a TBI and 34 developed dementia. Brain injury was associated with younger age at detection of dementia even when adjusted for sex and educational status (low educational status significantly associated with dementia); age-specific hazard ratio (95% confidence interval) 2.80 (1.35-5.81). In a population scoring > or =28 points in the baseline MMSE an apolipoprotein E (ApoE) epsilon4 phenotype was also associated with younger age at the time of detecting dementia; 3.56 (1.35-9.34), and the effect of brain injury and ApoE epsilon4 phenotype was synergistic; 7.68 (2.32-25.3). We conclude that fall-related TBI predicts earlier onset of dementia and the effect is especially high amongst subjects who carry the ApoE epsilon4 allele.

Factors predicting the relapse of depression in old age.

BACKGROUND: Studies in mixed-aged populations show differences between the predictors of a relapse and those of a long-term course of depression, supporting the hypothesis about similar differences among the aged. AIM: The aim was to identify the factors predicting or related to a relapse of depression among the Finnish elderly having recovered from depression during treatment. MATERIAL AND METHODS: The population consisted of 70 depressed (DSM-III criteria) elderly (60 yr-) Finns having recovered from depression during treatment as determined 15 months after baseline. By the 4-year follow-up after the recovery, 20 patients had relapsed and 50 persons were non-depressed. RESULTS: The logistic regression model showed major depression and psychomotor retardation to be independent predictors. Relapses were not related to stressors in life or physical illnesses occurring during the follow-up. CONCLUSIONS: Major depressive elderly patients have a high risk for relapses without the occurrence of the stressors or physical illnesses. In clinical practice, major depressive elderly patients should be followed up in order to detect and treat potential relapses as early as possible. Cooperation between psychiatrists and general practitioners is needed in the follow-up. Theoretically, the results suggest the assumption of a biochemical aetiology of major depression.

Factors predicting chronicity of depression in elderly primary care patients.

AIM: The aim was to identify the factors predicting and related to chronicity of depression among depressed Finnish elderly subjects. MATERIAL AND METHODS: The study consisted of 97 depressed (DSM-III criteria) elderly (60 years or older) Finns treated in primary health care. The occurrence of depression was assessed after treatment and follow-up periods of about 15 months and 5 years, and the persons were classified according to their recovery: (a) persons depressed in all the three examinations (the chronically depressed) (n = 47), and (b) persons depressed in the first examination, but nondepressed in both follow-up examinations (the recovered) (n = 50). RESULTS: Diurnal variation of symptoms and poor self-appreciation at the baseline and the onset of a severe disease, the deterioration of one's health status, and the death of a family member during the follow-up emerged as independent predictors or associates of the chronic course of depression in the logistic regression model. CONCLUSIONS: Depressed elderly subjects who develop a physical disease or whose family member dies during the treatment of depression have a high risk for a chronic course. Intensive antidepressant and psychotherapeutic treatment and adequate physical treatment of these patients are proposed, in order to increase the probability of recovery from depression.

Depression in elderly spouse pairs.

OBJECTIVE: This study aimed to investigate the prevalence of depression in aged spouse pairs and the associations between the occurrence of depression in one spouse (respondent) and the variables representing the respondent himself/herself and his/her partner. METHOD: Elderly (65 years or older) male (N = 176) and female (N = 176) spouses who constituted married couples that had participated in the epidemiological study on depression in old age conducted in Ahtäri, Finland, in 1989-1990 made up the study series. The data were collected by postal questionnaires, interviews, and clinical investigations. Depression was determined according to the DSM-III criteria. RESULTS: Both husband and wife were depressed in 5.7% of the married couples. The husband was depressed and the wife was nondepressed in 10.2% of the couples; and the wife was depressed and the husband nondepressed in 10.8% of the couples. Among male respondents, poor physical health of the respondent, poor marital or family relations felt by the respondent, poor family relations felt by the marital partner, and a loss of the father by the marital partner while the partner was under 20 years of age were independently related to depression. Lowered functional abilities of the respondent was the only factor independently associated with the occurrence of depression in female respondents. CONCLUSIONS: The coexistence of depression in both elderly spouses is not uncommon. The results also give some evidence to suggest that the vulnerability for the development of depression in the wives may have some effects on the development of depression in elderly men.

Dementia with Lewy bodies according to the consensus criteria in a general population aged 75 years or older.

OBJECTIVE: To estimate the prevalence of dementia with Lewy bodies (DLB) according to the consensus criteria in a general population aged 75 years or older. METHODS: The "Kuopio 75+ study" is a population based health survey focused on the clinical epidemiology of dementia and functional capacity among elderly subjects aged 75 years or older. On 1 January 1998, a random sample of 700 subjects was drawn from a total population born before 1 January 1923, living in the city of Kuopio, northeast Finland (n = 4518). The study subjects underwent a structured interview and clinical examination. RESULTS: 601 elderly subjects (86% of the random sample) were examined. A dementia disorder was diagnosed in 137-a prevalence of 22.8% (95% confidence interval 19.4% to 26.2%). The prevalence of DLB was 5.0% (3.2% to 6.7%), comprising 22% of all demented subjects. Probable DLB was diagnosed in 20 subjects (3.3% (1.9% to 4.8%)), and possible DLB in 10 (1.7% (0.6% to 2.7%)). The prevalence of Alzheimer's disease was 10.6% (47% of all demented subjects), of vascular dementia, 5.3% (23%), and of other types of dementing disorders, 1.8% (8%). CONCLUSIONS: In a general population aged 75 years and older, the prevalence of a disorder fulfilling the diagnostic criteria of DLB is half that of Alzheimer's disease and the same as for vascular dementia.

Poor performance in the mini-mental state examination due to causes other than dementia.

OBJECTIVE: The aim of this study was to examine the extent to which causes other than dementia contribute to poor performance on the Mini-Mental State Examination (MMSE). DESIGN: Cross-sectional population-based study. SETTING: Municipality of Lieto, Finland. SUBJECTS: The study population consisted of all individuals residing in Lieto and born in or before 1926. A total of 1196 individuals, 93% of those eligible, participated. MAIN OUTCOME MEASURES: The MMSE was implemented following interviews and clinical examinations. Whenever an individual was unable to complete any individual item on the MMSE, the nurse recorded causes and assessed whether poor performance was mainly caused by dementia or other reasons. RESULTS: Poor test performance due to causes other than dementia was recorded in 122 (10.2%) individuals (4% of those in the 64-74 years group, 15% in the 75-84 years group and 42% in the group of 85 years of age or older). The most common causes were poor vision and hearing, deficient schooling and consequences of stroke. CONCLUSION: Ten percent of the elderly population had symptoms contributing to poor performance on the MMSE. Physicians should therefore consider and record co-morbidity in the testing situation, especially in very old individuals.

Apolipoprotein E, cognitive function, and dementia in a general population aged 85 years and over.

We examined 510 subjects representing 83.2% of all citizens of a Finnish city aged 85 years or over. Mini-Mental State Examination (MMSE) scores, diagnosis of dementia by DSM-III-R criteria, and Apo-E genotype were determined. The prevalence of dementia was 38.6%. The odds ratio (OR) of the Apo-E epsilon4 carriers (with the reference population of people with the genotype epsilon3/epsilon3) for dementia was 2.36 (95% CI 1.58 - 3.53). There was a significant sex difference: The OR in women was 3.23 (95% CI 2.02 - 5.17) whereas among men it was insignificant. The mean MMSE score (+/- SD) among the Apo-E epsilon4 carriers (15.0 +/- 10.0) and noncarriers (18.7 8.6) (p < .001) differed among the whole population, but not within the demented or nondemented subjects analyzed separately. This study does not support the hypothesis that the Apo-E epsilon4 allele impairs cognitive functions of nondemented elderly, at least in those surviving to very old age.

Early loss of mother or father predicts depression in old age.

The independent predictive roles of early losses, personality traits, acute losses and long-term stress situations for the occurrence of depression in elderly Finns were described using a longitudinal design. The persons non-depressed in an epidemiological study in 1984-85 were interviewed in 1989-90 (N = 679) and the occurrence of depression was determined according to DSM III-criteria. Logistic regression models were used to assess the independent roles of the hypothesized factors as predictors. An early loss of the mother among men and an early loss of the father among women independently predicted the occurrence of depression in logistic regression models. Older age in men, and a higher number of symptoms, the occurrence of previous depression and not living alone in women were also independent predictors. In men, impaired functional abilities and poor self-perceived health tended to predict depression. In conclusion, the psychological trauma which develops upon the experience of an early parental loss contributes to the development of depression even in old age. The role of stressors in life as independent predictors of depression in old age was also ascertained.