Differences between suicide attempters and nonattempters in depressed older patients: depression severity, white-matter lesions, and cognitive functioning.

OBJECTIVES: The population of older adults with major depressive disorder (MDD) has the highest rate of suicide. White-matter brain lesions (WML) are a potential biologic marker for suicidality in young and middle-aged adults and are correlated with cognitive impairment in older adults. In this study of older patients with MDD, we examined 1) if a history of suicide attempts was associated with a more severe course of MDD; 2) if WML are a biologic marker for suicide; and 3) if suicide attempt history is associated with cognitive impairment mediated by WML. SETTING: Data from the Neurocognitive Outcomes of Depression in the Elderly study. PARTICIPANTS: Depressed patients (60+) who had ever attempted suicide (n = 23) were compared with depressed patients (60+) who had not attempted suicide (n = 223). MEASUREMENTS: Baseline and follow-up assessments were obtained for depressive symptoms (every 3 months) and cognitive functioning (every 6 months) over 2 years. Three magnetic resonance imaging scans were conducted. RESULTS: At baseline, suicide attempters reported more severe past and present symptoms (e.g., depressive symptoms, current suicidal thoughts, psychotic symptoms, earlier age of onset, and more lifetime episodes) than nonattempters. Suicide attempters had more left WML at baseline, and suicide attempt history predicted a greater growth in both left and right WML. WML predicted cognitive decline; nonetheless, a history of suicide attempt was unrelated to cognitive functioning. CONCLUSIONS: Severity of depressive symptoms and WML are associated with suicide attempts in geriatric depressed patients. Suicide attempts predicted neurologic changes, which may contribute to poorer long-term outcomes in elder attempters.

Melancholia in later life: late and early onset differences in presentation, course, and dementia risk.

OBJECTIVES: Depression is a risk factor for cognitive decline and dementia. This risk may vary with age of onset and depression subtype. Late onset depression (LOD, 60 years and older) is associated with more cognitive decline, whereas early onset depression (EOD, before 60 years) is associated with more residual depressive symptoms. Potential differences may reflect divergent etiologies. These onset differences, however, have not been examined in the melancholic subtype of depression in older adults. METHODS: Data were obtained from the Neurocognitive Outcomes of Depression in the Elderly study. Participants (N = 284, 73% EOD-melancholic (EOD-M) and 27% LOD-melancholic (LOD-M)) were followed up over 3 years. Factor analyses examined differences in baseline depressive symptoms. Hierarchical linear growth curve models examined changes in depressive symptoms (Montgomery-Asberg Depression Rating Scale) and cognition (mini mental state examination). An annual clinical review panel assigned diagnoses of dementia. RESULTS: The LOD-M participants had more vegetative symptoms at baseline. LOD-M exhibited greater cognitive decline but fewer residual depressive symptoms than EOD-M. Among participants who remained in the study for at least 1 year, in uncontrolled analyses, a greater percentage of LOD-M compared with EOD-M developed dementia (23.0% vs. 7.8%). Whereas in logistic analyses, controlling for baseline demographics, age at onset remained a predictor of dementia, the odds ratio suggested that the effect was relatively small. CONCLUSIONS: The EOD-M and LOD-M participants have a different presentation and course. LOD-M may represent a syndrome of neuropsychiatric deterioration with expression of both depressive symptoms and cognitive decline.

The influence of prior rape on the psychological and physical health functioning of older adults.

OBJECTIVES: Older adults who have experienced traumatic events earlier in life may be especially vulnerable to additional challenges associated with aging. In a cross-sectional study of older females, the present study examines whether a history of rape is associated with current psychological and health problems. METHOD: This study used existing data from the female respondents (N = 1228) in the National Social Life, Health, and Aging Project (NSHAP), a national probability sample of adults between the ages of 57 and 85 interviewed in their homes. It was determined whether or not the participant experienced forced sexual contact since the age of 18. Measures of psychological health (e.g., scales of depression, anxiety, and loneliness), the presence or absence of a number of serious health problems, and a one-item measure of self-esteem were obtained. RESULTS: Adult rape occurred in 7% of the sample. On average, 36 years had elapsed since the rape had occurred. Using structural equation modeling (SEM), rape was associated with lower self-esteem, psychological, and physical health functioning. Self-esteem partially mediated the association between rape and psychological functioning, but not health functioning. These associations were significant even after controlling for participant characteristics and risky health behaviors. CONCLUSIONS: Mechanisms linking prior rape to psychological and health problems in older age are discussed, as well as treatment recommendations for symptomatic older adults.

Early childhood abuse and late-life suicidal ideation.

OBJECTIVES: In younger populations childhood sexual and physical abuse have been found to be associated with suicidal ideation. Such associations have not been examined among older adults. SETTING: Data from the National Comorbidity Study-Replication (NCS-R). PARTICIPANTS: Older adults (60+, N = 1610) from the NCS-R sample. MEASUREMENTS: Suicidal ideation occurring after the age of 60 was assessed. Early-life factors were assessed including childhood physical and sexual abuse and parent's internalizing and externalizing symptoms. Participants' internalizing and externalizing symptoms were also assessed. RESULTS: Logistic regression analysis showed that male gender, mother's internalizing symptoms and childhood physical and sexual abuse were associated with suicidal ideation. The association between child abuse and suicidal ideation was mediated by participants' externalizing symptoms. CONCLUSIONS: Health care workers should screen for suicidal ideation among older adults. In particular, older males with externalizing disorders and a history of child abuse may be at a heightened risk for suicidal ideation.

The relationship of religious involvement indicators and social support to current and past suicidality among depressed older adults.

Elderly people, particularly those with major depression, are at the highest risk for suicide than any other age group. Religious involvement is associated with a range of health outcomes including lower odds of death by suicide. However, not much is known about the effects of religious involvement on suicidal ideation in the elderly or which aspects of religiosity are beneficial. This study examined the relative influence of various conceptualizations of religious involvement, above and beyond the protective effects of social support, on current and past suicidality among depressed older adults. Participants were 248 depressed patients, 59 years and older, enrolled in the Neurocognitive Outcomes of Depression in the Elderly study. A psychiatrist assessed current suicidal ideation using the suicidal thoughts item from the Montgomery-Asberg Depression Rating Scale. Past history of suicide attempts, four religious involvement indicators, social support indicators, and control variables were assessed via self-report. Church attendance, above and beyond importance of religion, private religious practices, and social support, was associated with less suicidal ideation; perceived social support partially mediated this relationship. Current religious practices were not predictive of retrospective reports of past suicide attempts. Church attendance, rather than other religious involvement indicators, has the strongest relationship to current suicidal ideation. Clinicians should consider public religious activity patterns and perceived social support when assessing for other known risk and protective factors for suicide and in developing treatment plans.

A longitudinal study of differences in late- and early-onset geriatric depression: depressive symptoms and psychosocial, cognitive, and neurological functioning.

OBJECTIVES: Studies suggest early-onset depression (EOD) is associated with a more severe course of the depressive disorder, while late-onset depression (LOD) is associated with more cognitive and neuroimaging changes. This study examined if older adults with EOD, compared with those with LOD, would exhibit more severe symptoms of depression and, consistent with the glucocorticoid cascade hypothesis, have more hippocampal volume loss. A second goal was to determine if LOD, compared with EOD, would demonstrate more cognitive and neuroimaging changes. METHOD: At regular intervals over a four-year period non-demented, older, depressed adults were assessed on the Mini-Mental Status Examination and the Montgomery-Asberg Depression Rating Scale. They were also assessed on magnetic resonance imaging. RESULTS: Compared with LOD, EOD had more depressive symptoms, more suicidal thoughts, and less social support. Growth curve analyses indicated that EOD demonstrated higher levels of residual depressive symptoms over time. The LOD group exhibited a greater decrement in cognitive scores. Contrary to the glucocorticoid cascade hypothesis, participants with EOD lost right hippocampal volume at a slower rate than did participants with LOD. Right cerebrum gray matter was initially smaller among participants with LOD. CONCLUSIONS: EOD is associated with greater severity of depressive illness. LOD is associated with more severe cognitive and neurological changes. These differences are relevant to understanding cognitive impairment in geriatric depression.

Depressed older patients with the atypical features of interpersonal rejection sensitivity and reversed-vegetative symptoms are similar to younger atypical patients.

OBJECTIVES: The atypical depression (AD) subtype has rarely been examined in older patients. However, younger AD patients have been characterized as having more severe and chronic symptoms of depression compared with non-AD patients. DESIGN: Secondary data analysis by using analyses of variance and Growth Curve Modeling. SETTING: Clinical Research Center for the study of depression in later life. PARTICIPANTS: Depressed older patients (N = 248) followed over 2 years. METHOD: In a longitudinal study, we examined depression severity and chronicity in patients with major depression with some features of AD, specifically rejection sensitivity and reversed-vegetative symptoms (e.g., hyperphagia and hypersomnia), or leaden paralysis, and compared them to non-AD patients. The Diagnostic Interview Schedule (DIS) was used to assess depressive symptoms and history. Depression severity and chronicity were assessed every 3 months by using the Montgomery Asberg Depression Rating Scale. RESULTS: The AD symptom group reported more DIS depressive symptoms, more thoughts about wanting to die, earlier age of onset, poorer social support, and double the number of lifetime episodes than non-AD patients. Growth curve analyses revealed that, compared with non-AD patients, the AD symptom group had more residual symptoms of depression during the first year of follow-up but not during the second year. CONCLUSION: Characteristics of older patients with features of AD are similar to younger patients. Assessment of atypical symptoms, in particular, rejection sensitivity and reversed-vegetative symptoms, is essential and should be considered in treatment plans.

Depression, hippocampal volume changes, and cognitive decline in a clinical sample of older depressed outpatients and non-depressed controls.

OBJECTIVE: The aim of this study was to develop and test a model of depression, hippocampal changes, and cognitive decline. METHOD: Participants were 248 community-dwelling, depressed patients and 147 healthy, non-depressed individuals 60 years and older. Participants received a structured interview assessing current depressive symptoms and past depressive episodes, completed cognitive testing with the Mini Mental State Examination (MMSE), and underwent structural Magnetic Resonance Imaging (MRI) of the brain. For up to 10 years, assessment of depressive symptoms and MMSE administration was repeated at least annually, and MRI was repeated every two years. RESULTS: Regression analyses demonstrated that depression diagnosis at baseline predicted decrease in right (but not left) hippocampal volume over a four-year period. Analyses using structural equation modeling demonstrated that a decrease in left and right hippocampal volumes predicted decrease in MMSE score over four years. CONCLUSION: Results provide some evidence for relationships between depression and decrease in right hippocampal volume, and between hippocampal volume and MMSE score. This would be consistent with depression as a causal factor in subsequent cognitive decline. Plausible biological mechanisms include a glucocorticoid cascade or a facilitating effect of depression on amyloid-beta plaque formation. Future studies should examine the relationship between hippocampal volume and specialized memory measures, as well as between depression diagnosis and volume of other brain structures.

The moderating effect of the APOE [small element of] 4 allele on the relationship between hippocampal volume and cognitive decline in older depressed patients.

OBJECTIVE: the apolipoprotein E epsilon-4 (APOE [small element of] 4) allele and depression are independently associated with increased risk for cognitive decline (CD). The authors have reported that depressed elders with an APOE [small element of]4 allele had greater CD compared with depressed elders without the allele. Depression affects the hippocampus, and reduced hippocampal volume has been associated with CD. This study sought to examine in depressed patients the relationships between hippocampal volume, the APOE [small element of] 4 allele, and their interaction on CD. Analyses were performed to examine the influence of baseline hippocampal volume, the APOE [small element of] 4 allele, and their interactions on change in cognitive functioning overtime. DESIGN: secondary data analysis using linear regression analyses. SETTING: clinical Research Center for the Study of Depression in Later Life conducted at Duke University. PARTICIPANTS: depressed older patients (N = 61) followed up for 4 years. MEASURES: At baseline, cognitive functioning (assessed by the Mini-Mental State Examination), left and right hippocampal volume (assessed by magnetic resonance imaging), and APOE genotype were obtained. At 4-year follow-up, cognitive functioning was reassessed. RESULTS: the APOE [small element of] 4 allele and left hippocampal volume, but not right hippocampal volume, were independently associated with CD. Importantly, the authors found the APOE [small element of]4 allele to moderate the effects of left hippocampal volume on CD. The APOE [small element of]4 allele seemed to have little effect among those with larger left hippocampal volumes, whereas the allele influenced CD among those with smaller hippocampal volumes. CONCLUSION: future studies of cognitive impairment and decline should examine both individual and conjoint effects of putative risk factors.

Problems meeting basic needs moderate the association between the APOE epsilon4 allele and cognitive decline.

OBJECTIVES: The ApolipoproteinE epsilon4 (APOE epsilon4) allele influences cognitive decline (CD) in some but not in all individuals. The purpose of this study was to investigate whether problems meeting basic needs (BN) (e.g., having enough money to meet needs, having enough money for emergencies, having adequate housing, and having enough heat) influences the relationship between the APOE epsilon4 allele and CD. We predicted that problems meeting BN would have a greater influence on CD among those with the APOE epsilon4 allele than those without the allele. METHODS: Participants consisted of community-dwelling older adults from the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE). Data were drawn from Waves 1 and 2, which were 3 years apart. Cognitive functioning was assessed at both waves so that change in cognitive status was examined over time, and cognitive status was controlled at baseline. Genotyping, however, was not obtained until Wave 3. RESULTS: The APOE epsilon4 allele and problems meeting BN independently predicted CD. Importantly, the influence of BN on CD was greater for individuals with the APOE epsilon4 allele compared to those without the allele. Other indicators of socioeconomic status (e.g., education, income) did not interact with the APOE epsilon4 allele in predicting CD. CONCLUSIONS: There is a synergistic effect of perceived problems meeting BN and the APOE epsilon4 allele on jointly influencing cognitive functioning. Although genetic risk factors are not easily modifiable, resource deprivation may be more amenable to interventions, which may reduce risk for CD.

APOE epsilon4 allele carriers: Biological, psychological, and social variables associated with cognitive impairment.

OBJECTIVE: The apolipoprotein (APOE) epsilon4 allele genotype is a risk factor for dementia, but not all people with the APOE epsilon4 allele develop cognitive impairment (CI). Among participants with the APOE epsilon4 allele (N = 664), we identified biological, psychological, and social variables that discriminate between participants who develop CI from those who do not. We then determined if these variables predicted CI in noncarriers (N = 1421). In the sample as a whole we then determined if each of these identified variables moderate the relationship between the APOE epsilon4 allele and CI. METHODS: We used data from a biracial community-dwelling sample of older adults. Data were collected at four time points over a 10-year period. Cognitive functioning was assessed at each wave, using the Short Portable Mental Status Questionnaire (SPMSQ). APOE genotyping was performed at Wave 3. RESULTS: Among APOE epsilon4 allele carriers, but not noncarriers, variables associated with CI included white race, female gender, low BMI, number of negative life events, and health problems (high blood pressure, heart disease, and stroke). In analyses testing for moderate effects and including the entire sample, significant interactions with APOE epsilon4 allele and predictor variables revealed that white race, low BMI, stroke, heart disease, and negative life events had a greater effect on CI among those with the APOE epsilon4 allele compared to those without the allele. CONCLUSION: There are biological, psychological, and social variables associated with increased risk for CI among individuals with the APOE epsilon4 allele.

The long-term impact of childhood abuse on internalizing disorders among older adults: the moderating role of self-esteem.

OBJECTIVES: First, to determine if childhood experiences of abuse have an impact on internalizing disorders (e.g., anxiety and depressive disorders) among older adults. Second, we wish to determine if self-esteem plays a role in explaining the relationship between abuse and internalizing disorders. METHOD: First, we conducted an analysis on a population sample of participants aged 50 years or older (mean age = 67 years; SD = 10.3) assessed at two time points, three years apart (Wave 1, N = 1460; Wave 2, N = 1090). We examined the relationship between reports of childhood abuse (physical, emotional, and sexual) and internalizing disorders. Second, we determined the role self-esteem played in explaining the relationship. RESULTS: We found that childhood experiences of abuse assessed at Wave 1 predicted the number of DSM-IV internalizing disorders occurring three years later. Demonstrating the specificity of self-esteem; we found self-esteem, but not emotional reliance, to moderate the relationship between abuse and internalizing disorders such that childhood abuse had more negative effects on those with low self-esteem compared to those with higher self-esteem. Contrary to prediction, self-esteem did not mediate the relationship between abuse and internalizing disorders. CONCLUSION: The negative effects of childhood abuse persist for many years, even into older adulthood. However, contrary to the findings in younger adults, self-esteem was not correlated with childhood abuse in older adults. Moreover, childhood abuse only had a negative effect on those who had low self-esteem. It may be through the process of lifespan development that some abused individuals come to separate out the effects of abuse from their self-concept.

Depressive symptoms moderate the influence of the apolipoproteine epsilon4 allele on cognitive decline in a sample of community dwelling older adults.

OBJECTIVES: The apolipoproteinE epsilon4 (APOE epsilon4) allele and a history of depression are each separate risk factors for cognitive decline (CD). However, little research has investigated whether a history of depression influences the relationship between APOE epsilon4 and CD. The present study examined whether depressive symptoms had greater influence on subsequent CD among participants with APOE epsilon4 than those without the allele. DESIGN: Prospective 6-year longitudinal study. SETTING: Community in-home interviews. PARTICIPANTS: A biracial sample of community dwelling older adults (N = 1,992) from the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE). MEASUREMENTS: Data were drawn from Waves 1 to 3 of the EPESE, which were conducted 6 years apart. Cognitive functioning and depressive symptoms were assessed at both waves, and APOE genotyping was completed during the Wave 3 assessment. RESULTS: Regression analyses revealed that depressive symptoms and the APOE epsilon4 allele independently predicted CD. Importantly, the influence of depressive symptoms on CD was greater for individuals with the APOE epsilon4 allele compared with those without the allele. CONCLUSION: Depressive symptoms and the APOE epsilon4 allele are independent contributors to CD. Moreover, the influence of depressive symptoms on CD is greater among individuals with the APOE epsilon4 allele. Depression and the APOE epsilon4 allele may act together in disrupting neurological functioning, which may in turn lower an individual's cognitive reserve capacity. Given the efficacious treatments currently available for depression, future research should investigate the extent to which interventions for depression may reduce the risk for subsequent CD.

Well-being of family caregivers of persons with late-stage Huntington's disease: lessons in stress and coping.

The utility of a stress-process model in predicting health and quality-of-life outcomes for family caregivers of persons with Huntington's disease (HD) was tested. HD is an inherited neurodegenerative disease that poses particular challenges to patients and families. Seventeen family caregivers were interviewed and completed scales measuring stressors, appraisals, protective factors, and outcomes. No direct relationship between stress and caregiver well-being was found; the impact of stressors was mediated by appraisals and protective factors. Bivariate correlation analysis revealed significant positive relationships between satisfaction with emotionally supportive communication and life satisfaction. Significant positive correlations were found between positive appraisals of the benefits of the caregiving experience and life satisfaction and health. Mastery was significantly positively correlated with life satisfaction and negatively correlated with depressive symptoms; similar results were found between spirituality and outcome measures. Caregivers' interpretations appeared to have a more significant impact on well-being than did objective characteristics of the experience.

Problems meeting basic needs predict cognitive decline in community-dwelling Hispanic older adults.

Objectives. Indices of low socioeconomic status (SES) have been found to predict negative health outcomes. However, problems meeting basic needs (e.g., not having enough money for health care, adequate food, etc.) may be a more potent measure of negative health outcomes than other more typically assessed indices of SES, such as income. This article examined the association between problems meeting basic needs and cognitive decline in a sample of community-dwelling Hispanic older adults (N = 1,964). Method. The authors used a prospective design to study the influence of problems meeting basic needs on cognitive functioning. Analyses controlled for demographics, health problems, and depressive symptoms. Results. The authors found problems meeting basic needs to be a more potent predictor of cognitive decline than income. Discussion. Interventions focused on providing older adults with resources for meeting basic needs, such as adequate food and health care, may substantially reduce the subsequent level of stress and health problems in this population.

Religious attendance reduces cognitive decline among older women with high levels of depressive symptoms.

BACKGROUND: There is growing evidence that regular attendance at religious functions is associated with less cognitive decline (CD). However, little research has investigated factors that may moderate the religious attendance-CD relationship. The present study examined the effects of gender and depressive symptoms on the relationship between religious attendance and CD. METHODS: Data were drawn from waves 1 and 2 of the Duke Established Populations for Epidemiologic Studies of the Elderly, which were 3 years apart. Participants consisted of a sample of community-dwelling older adults aged 65 years and older (N = 2,938). Linear regression analyses were conducted controlling for important demographic-, socioeconomic-, and health-related variables. Cognitive functioning was assessed at both waves to examine change in errors over time. RESULTS: Greater religious attendance was related to less CD. In addition, there was a three-way interaction between religious attendance, gender, and depressive symptoms in predicting CD. Among women with higher levels of depressive symptoms, those who less frequently attended religious services experienced greater CD than those who more frequently attended religious services. The interaction between attendance and depressive symptoms in men did not reach significance. CONCLUSIONS: Religious attendance may offer mental stimulation that helps to maintain cognitive functioning in later life, particularly among older depressed women. Given the possible benefits religious attendance may have on cognitive functioning, it may be appropriate in certain instances for clinicians to recommend that clients reengage in religious activities they may have given up as a result of their depression.