MRI-defined vascular depression.

OBJECTIVE: The authors' goal was to characterize the clinical and demographic features of vascular depression. METHOD: They classified 89 depressed patients into two groups-those with vascular (N = 32) and nonvascular (N = 57) depression-on the basis of examination of brain magnetic resonance images. All of the patients were enrolled in the National Institute of Mental Health Clinical Research Center for the Study of Depression in Later Life, located at Duke University. The patients with vascular and nonvascular depression were compared on several clinical and demographic risk factors. RESULTS: Bivariate analyses and a fully adjusted logistic regression model revealed that older age, late age at onset, and nonpsychotic subtype occurred more often in patients with vascular depression than in those with nonvascular depression. A family history of mental illness was found somewhat less often, and anhedonia and functional disability were seen somewhat more often in patients with vascular depression. CONCLUSIONS: The profile of patients with vascular depression needs to be developed further. This is likely to have important therapeutic and theoretical implications for the management of these patients.

Clinical and phenomenological comparisons of late-onset and early-onset depression.

OBJECTIVE: The authors examined the relationship between age at onset of first depressive episode and clinical features in elderly depressed patients. METHOD: They used data on age at onset and clinical features in 246 elderly depressed patients treated at the National Institute of Mental Health Clinical Research Center for the Study of Depression in Later Life, located at Duke University. RESULTS: Two variables--loss of interest and number of depressive episodes--were related to age at onset in all analyses. CONCLUSIONS: This study confirms the hypothesis that apathy is more prominent in late-onset than in early-onset depression.

Does social support buffer functional decline in elderly patients with unipolar depression?

OBJECTIVE: This study tested whether social support protects against functional decline, either generally or selectively, in the most severely depressed elderly patients undergoing treatment for major depressive disorder. METHOD: In a prospective cohort study design, 113 patients with incident and prevalent unipolar depression were followed for 12 months while they were undergoing naturalistic treatment. Outcome measures included performance on basic and instrumental activities of daily living; predictor variables included Hamilton Depression Rating Scale scores and four domains of informal social support. The analysis employed multivariable ordinary least squares regression models. RESULTS: Improved scores on instrumental activities of daily living and stable scores on basic activities of daily living characterized the subjects. In adjusted analyses, instrumental social support provided marginal protection against worsening performance on instrumental activities of daily living, which were primarily a function of baseline depression severity. Large social networks, more frequent social interaction, and the perceived adequacy of social support played a modest buffering role against declines in performance on basic activities of daily living among the most depressed elderly patients. CONCLUSIONS: Instrumental support was generally protective against worsening performance on instrumental abilities of daily living among elderly patients with recurrent unipolar depression. Subjective and structural dimensions of social support protected the most severely depressed elderly patients against the loss of basic maintenance abilities.

Incidence and remission of insomnia among elderly adults in a biracial cohort.

OBJECTIVES: To determine the incidence and remission rates of insomnia in older adults according to race and associated risk factors in a three-year longitudinal study. METHODS: 2,971 men and women, aged 65 years and older, completed questionnaires administered by trained interviewers at baseline and three years later. Data concerning difficulty falling asleep or early morning arousal (insomnia), along with self-reports of physical disability, respiratory symptoms, depressive symptomatology, perceived health status, and use of prescribed sedative medication, were collected and analyzed. RESULTS: Overall, 15% of the participants without symptoms of insomnia at baseline reported chronic difficulty falling asleep or early morning arousal three years later in follow-up interviews. African-American women had a significantly (p < 0.01) higher incidence of insomnia (19%) compared with African-American men (12%) or with white men and women (both 14%). Men were more likely than women to no longer report symptoms at follow-up (64% vs 42%; p < 0.01). For both races, the presence of depressed mood was a risk factor for the incidence of insomnia, and the absence of depressed mood was a predictor of remission. CONCLUSIONS: Insomnia occurs more frequently in African-American women than in African-American men or than in white men or women. Regardless of race, women are less likely than men to resolve their insomnia. The high prevalence and incidence of morbidity in elderly African-American women may contribute to their high rate of insomnia.

Are sleep complaints an independent risk factor for myocardial infarction?

PURPOSE: To investigate whether subjective sleep complaints are an independent predictor of myocardial infarction (MI) in a community of older adults and to gain clues as to why the association between sleep complaints and incident MI exists. METHODS: Using longitudinal data from the Piedmont study on 2960 adults aged 65 or older who were free of symptomatic heart disease at baseline, we screened 19 potential confounders to determine if any, alone or in combination, could explain the observed relationship between incident MI and sleep complaints. RESULTS: During the three-year follow-up period, there were 152 incident MIs. Restless sleep (incidence density ratio (IDR) = 1.58, 95% confidence interval (CI) = 1.11, 2.24) and trouble falling asleep (IDR = 1.68, 95% CI = 1.09, 2.60) predicted incident MI after adjusting for age, gender, and race. IDRs were not substantially impacted by controlling for smoking, blood pressure, diabetes or obesity. After adjustment for education, number of prescription medicines, self-rated health, and depression score, all IDRs were nullified. In particular, self-rated health and depression were strong independent risk factors for MI. CONCLUSIONS: A subjective sleep complaint increases the likelihood of a first MI in older adults without overt coronary heart disease (CHD) independently of classic coronary risk factors and appears to be a marker for a syndrome of depression and malaise that may have a causal relationship to MI.

Global self-ratings of health and mortality: hazard in the North Carolina Piedmont.

We analyzed the first 5 years of surveillance data from the Established Population for the Epidemiologic Studies of the Elderly (EPESE) in the Piedmont of North Carolina (n = 4162) to estimate the effect of a global self-rating of health on survival. Covariates used in Cox proportional hazard models included sociodemographic factors, chronic medical conditions, activities of daily living, use of health services, health risk behaviors, cognitive function, affective mood, and negative life events. Adjusted risk of mortality associated with poor (compared to excellent) self-ratings of health was significantly elevated among urban men only. Confounders of the association between survival and overall health assessment varied widely by subgroup. Pooled estimates from heterogeneous populations may mask significant subgroup differences both in the pattern of variables that mediate crude risk and also in the magnitude of residual risk of global self-ratings of health.

Past personal history of dysphoria, social support, and psychological distress following conjugal bereavement.

OBJECTIVE: This study describe the course and risk factors of psychological distress following bereavement, controlling for factors often omitted from studies of grief: psychiatric history, social support, and coping choices of the bereaved. PARTICIPANTS: Spouses of patients hospitalized for serious illness or elective surgery were systematically screened and followed longitudinally through the recovery or death of the hospitalized patient. Of 440 respondents, 154 were bereaved within 2 months. DESIGN AND SETTING: Spouses were interviewed in their homes by trained interviewers at intake and 2, 6, 13, and 25 months postintake. MEASUREMENTS: Dependent variables were measured with the CES-D (depressive symptoms) and the PERI (general anxiety and hopelessness/helplessness) scales. Independent variables were measured with the SADS-L (past personal history of dysphoria) and the Lazarus' Ways of Coping scale as well as sociodemographic measures. MAIN RESULTS: Lifetime prevalence of a brief period of dysphoric mood among spouses before the patient's illness was 22%; past personal history of dysphoric mood was related to female sex, smaller networks, and more depression and anxiety during the hospitalization of their spouses. Newly widowed persons with a past history of dysphoria perceived their networks to be relatively nonsupportive, but devoted similar amounts of coping effort to seeking social support and reported similar amounts of social interaction compared with persons with no history of dysphoria. Persons with a past history of dysphoria reported elevated levels of depressive symptoms, general anxiety, and hopelessness/helplessness through 25 months postbereavement, yet their recovery trajectory was similar to those without a past history of dysphoria. CONCLUSIONS: It was concluded that a past history of subsyndromal symptomatology in conjunction with a stressful life event such as bereavement increases one's vulnerability to excess psychological distress.

Risk of napping: excessive daytime sleepiness and mortality in an older community population.

OBJECTIVE: To describe the demographic and health-related factors related to excessive daytime sleepiness. To estimate the risk of mortality associated with excessive daytime sleepiness independent of nightime sleep problems and other factors that limit survival. DESIGN: Four-year prospective cohort study with annual interviews. SETTING: One urban and four rural counties in north-central North Carolina. PARTICIPANTS: Adults 65 years and older (n = 3962) living in the community. MAIN OUTCOME MEASURES: Excessive daytime sleepiness was measured as, "How often do you get so sleepy during the day or evening that you have to take a nap?" Mortality was based on continuous surveillance of the population by field investigators and abstraction of death certificates. RESULTS: Point prevalence of excessive daytime sleepiness in this population was 25.2%. Frequent daytime nappers were more likely than infrequent nappers to report nighttime sleep complaints and were more likely to be male and urban-dwellers, to report more depressive symptoms, more limited physical activity, and more functional impairment, and were more likely to be overweight. Of the frequent nappers, 23.9% died, compared with 15.4% of infrequent nappers. In an adjusted Cox proportional hazard model, the 4-year mortality rate was accelerated 1.73 times among older people who nap most of the time and make two or more errors on a cognitive status examination. CONCLUSION: Excessive napping is associated with impaired sleep hygiene as well as with a broad range of activity-related health deficits among community-dwelling older adults. Frequent napping was associated with impaired sleep hygiene, male gender, urban-dwelling, depressive symptoms, physical activity deficits, functional impairment, and excess weight. Mortality risk was elevated selectively among the most cognitively impaired subjects.

Impact of depressive symptoms on hospitalization risk in community-dwelling older persons.

OBJECTIVE: To determine whether depressive symptoms in older adults are associated with an increased risk for hospitalization. DESIGN: A 6 month cohort study. SETTING: Five counties in the northern Piedmont of North Carolina from the Duke University site of the Established Populations for Epidemiological Studies of the Elderly project. PARTICIPANTS: The sample included 3486 community-dwelling adults, aged 65 and older. MEASUREMENTS: Crude risk ratios for the effect of depressive symptoms on 6 month risk for hospitalization were calculated, followed by a multivariable analysis controlling for demographics and health status. RESULTS: Three hundred participants were hospitalized during the 6 month follow-up period. The crude risk ratio for the effect of depressive symptoms on hospitalization was 1.95 (95% CI = 1.47-2.58). Subgroup analysis showed significant positive risk ratios for men aged 65 to 74 and > or =75, and women aged 65 to 74. After a multivariable analysis, however, these associations remained significant only among men > or =75 (RR = 3.43; 95% CI = 1.33-8.86). CONCLUSIONS: Depressive symptoms were independently associated with a more than threefold increased risk for hospitalization among men aged > or =75. This result reflects differences in the effects of depressive symptoms across age and gender groups, and emphasizes that symptoms of depression influence overall health and medical utilization among, at the very least, the oldest subset of men.

Blood pressure and mortality risk in older people: comparison between African Americans and whites.

OBJECTIVES: To determine the risk from hypertension for all-cause mortality in a racially mixed sample of community-dwelling older adults. DESIGN: Baseline blood pressure was assessed between 1985 and 1986 in a sample of persons 65 years of age and older from five counties of the Piedmont of North Carolina (N = 4,162). All-cause mortality was monitored annually over the subsequent 6 years as part of the Established Populations for Epidemiologic Studies of the Elderly (EPESE) sponsored by the National Institute on Aging. SETTING: Eighteen percent of all respondents in the sample had a systolic blood pressure of > 160 (17% for whites and 18% for African Americans) and 16% had a diastolic blood pressure of >90 (14% for whites and 20% for African Americans). During the 6 years of follow-up, 29% of the sample died (with no difference in mortality rates between whites and African Americans). PARTICIPANTS: 4,000 community-dwelling people age 65 years and older; 1,846 were white and 2,154 were African American. MEASUREMENTS: Systolic and diastolic blood pressure and all-cause mortality. RESULTS: Systolic blood pressure positively related to mortality during the 6 years of follow-up (relative risk = 1.05). Among whites the relationship of diastolic pressure to mortality was nonlinear, with those at the upper and lower ends of the distribution at increased risk. Among African Americans, diastolic pressure was unrelated to mortality. The analyses were controlled for age; gender; education; body mass index (BMI); smoking history; taking a medication to manage blood pressure; a history of cancer, diabetes mellitus, heart attack, or stroke; poor subjective health; impaired functional status; and cognitive impairment. CONCLUSIONS: The findings confirm that among older adults there is a significant relationship overall between systolic blood pressure and mortality over 6 years of follow-up in both whites and African Americans. Diastolic pressure was a risk factor for whites only.

Elevated potassium intake inhibits neointimal proliferation in the swine coronary artery.

BACKGROUND: Previously, we reported that elevated extracellular potassium concentration in vitro inhibited proliferation and migration of vascular smooth muscle cells, formation of free radical compounds by macrophages, and reduced platelet sensitivity to agonists. More recently, we described a reduction in neointimal proliferation after balloon angioplasty injury in the carotid arteries of rats associated with an elevation of dietary potassium intake during a 4-week experiment. In the present study we conducted a similar investigation in the swine coronary artery balloon angioplasty model. PROCEDURES: Two groups of seven castrated male swine were studied; for 28 days the normal potassium group consumed a diet containing 0.25% potassium and the high potassium group ate diet containing 2.0% potassium. After 14 days on the diet, balloon angioplasty was performed. After an additional 14 days on the same diets the hearts were removed, and normal and lesioned sections of the artery were analyzed histologically. RESULTS: The neointimal area was markedly less in the high potassium group than in the normal potassium group, 0.33+/-0.04 mm2 v 0.74+/-0.10 mm2 (P < .004). Neointimal area-to-total wall area ratio in the normal potassium group averaged 0.199+/-0.018, significantly greater than the ratio computed for the elevated potassium group, 0.120+/-0.015 (P < .006). CONCLUSION: These results support the hypothesis that a high level of dietary potassium intake inhibits neointimal proliferation after balloon angioplasty in the swine coronary artery.

Sleep complaints in older adults: a racial comparison.

BACKGROUND: Sleep complaints have been reported in epidemiologic studies to be more frequent in late life, among females, among the physically impaired, and among persons experiencing psychiatric disorders. To date, however, no studies have reported a racial difference in sleep complaints among older persons in the United States. METHOD: The Duke EPESE (Established Populations for Epidemiologic Studies of the Elderly) assessed 3,976 community-dwelling elders age 65+ for sleep complaints and relevant control variables. RESULTS: In bivariate analyses, sleep complaints were associated with female gender, White race, older age, cognitive impairment, lower education, presence of chronic health conditions, poor self-rated health, and higher scores on a self-rated depression scale (the CES-D). In logistic regression analysis, the association of White race and more sleep complaints persisted (p < .001) when the above variables were simultaneously controlled. CONCLUSIONS: Fewer reported sleep complaints in community-dwelling Black elders compared to White elders remains unexplained, though it may be secondary to a higher threshold for Black elders reporting complaints.

Does private religious activity prolong survival? A six-year follow-up study of 3,851 older adults.

BACKGROUND: Previous studies have linked higher religious attendance and longer survival. In this study, we examine the relationship between survival and private religious activity. METHODS: A probability sample of elderly community-dwelling adults in North Carolina was assembled in 1986 and followed for 6 years. Level of participation in private religious activities such as prayer, meditation, or Bible study was assessed by self-report at baseline, along with a wide variety of sociodemographic and health variables. The main outcome was time (days) to death or censoring. RESULTS: During a median 6.3-year follow-up period, 1,137 subjects (29.5%) died. Those reporting rarely to never participating in private religious activity had an increased relative hazard of dying over more frequent participants, but this hazard did not remain significant for the sample as a whole after adjustment for demographic and health variables. When the sample was divided into activity of daily living (ADL) impaired and unimpaired, the effect did not remain significant for the ADL impaired group after controlling for demographic variables (hazard ratio [RH] 1.11, 95% confidence interval [CI] 0.91-1.35). However, the increased hazard remained significant for the ADL unimpaired group even after controlling for demographic and health variables (RH 1.63, 95% CI 1.20-2.21), and this effect persisted despite controlling for numerous explanatory variables including health practices, social support, and other religious practices (RH 1.47, 95% CI 1.07-2.03). CONCLUSIONS: Older adults who participate in private religious activity before the onset of ADL impairment appear to have a survival advantage over those who do not.

The relationship between religious activities and cigarette smoking in older adults.

BACKGROUND: The objective of this study was to examine the relationship between religious activities and cigarette smoking in community-dwelling older adults. METHODS: Cigarette smoking and religious activities were assessed in a probability sample of 3968 persons age 65 years or older participating in the Duke Populations for Epidemiologic Studies of the Elderly (EPESE) survey. Participants were asked if they currently smoked, if they ever smoked, and how many cigarettes per day they smoked. Attendance at religious services, participation in private religious activities (prayer or Bible study), and use of religious media (religious TV or radio) were also assessed. Data were available for Waves I-III of the survey (1986, 1989, and 1992). Analyses were controlled for age, race, sex, education, alcohol use, physical health, and in the longitudinal analyses, smoking status at prior waves. RESULTS: Cross-sectional analyses revealed that participants who frequently attended religious services were significantly less likely to smoke cigarettes at all three waves. Likewise, elders frequently involved in private religious activity were less likely to smoke (Waves II and III). Total number of pack-years smoked was also inversely related to both attendance at religious services and private religious activities. Watching religious TV or listening to religious radio, on the other hand, was not related to smoking at Waves I and II nor to total pack-years smoked, but was positively related to current smoking at Wave III. Among those who smoked, number of cigarettes smoked was inversely related to frequency of attendance at religious services (Wave I), private religious activities (Wave III), and religious TV/radio (Waves II and III). Retrospective and prospective analyses revealed that religiously active persons were less likely to ever start smoking, not more likely to quit smoking. CONCLUSIONS: Religiously active persons are less likely to smoke cigarettes, and if they do smoke, smoke fewer cigarettes. Given the association between smoking and disease, and the widespread prevalence of both smoking and religious activity, this finding has implications for public health.

Does religious attendance prolong survival? A six-year follow-up study of 3,968 older adults.

METHODS: A probability sample of 3,968 community-dwelling adults aged 64-101 years residing in the Piedmont of North Carolina was surveyed in 1986 as part of the Established Populations for the Epidemiologic Studies of the Elderly (EPESE) program of the National Institutes of Health. Attendance at religious services and a wide variety of sociodemographic and health variables were assessed at baseline. Vital status of members was then determined prospectively over the next 6 years (1986 1992). Time (days) to death or censoring in days was analyzed using a Cox proportional hazards regression model. RESULTS: During a median 6.3-year follow-up period, 1,777 subjects (29.7%) died. Of the subjects who attended religious services once a week or more in 1986 (frequent attenders), 22.9% died compared to 37.4% of those attending services less than once a week (infrequent attenders). The relative hazard (RH) of dying for frequent attenders was 46% less than for infrequent attenders (RH: 0.54, 95% CI 0.48-.0.61), an effect that was strongest in women (RH 0.51, CI 0.434).59) but also present in men (RH 0.63, 95% CI 0.52-0.75). When demographics, health conditions, social connections, and health practices were controlled, this effect remained significant for the entire sample (RH 0.72, 95% CI 0.64-.81), and for both women (RH 0.65, 95% CI 0.554-.76, p<.0001) and men (RH 0.83, 95% CI 0.69-1.00, p=.05). CONCLUSIONS: Older adults, particularly women, who attend religious services at least once a week appear to have a survival advantage over those attending services less frequently.

Sociodemographic and clinical correlates of number of previous depressive episodes in the depressed elderly.

Age of onset has been used as a correlate of depressive symptomatology in the elderly. Examining frequency of episodes may improve our ability to make such correlations. The authors studied variations in an index presentation of depression in late life based on the number of previous depressive episodes. Having more than two previous episodes (as compared to two or less) was related to younger age, early age of onset, dysthymia, feelings of worthlessness, difficulty concentrating, slowed thoughts, suicidal ideation, generalized anxiety, and decreased perceptions of social support. In a logistic regression model, significant predictors of more than two previous episodes were young age, early age of onset, dysthymia, suicidality, and lower perceived social support. Patients with many episodes may be at higher risk for more severe illness and may require more aggressive treatment.

Insomnia and heart disease: a review of epidemiologic studies.

Since the discovery and successful treatment of sleep apnea, researchers seem to believe that the association between sleep disturbance and coronary heart disease (CHD) has been explained. To determine whether subjective nighttime sleep complaints (trouble sleeping, trouble falling asleep, trouble staying asleep), exclusive of apnea, predicted myocardial infarction and other coronary events, a MEDLINE search was conducted for articles published between January 1976 through August 1997. Ten studies with an explicit measure of association between an insomniac complaint and CHD were identified. Reported risk ratios for various sleep complaints and CHD events ranged from 1.0 for waking too early and CHD death in an elderly North Carolina community to 8.0 for the highest versus lowest quintile of a sleep scale in Finnish men. Higher quality studies showed risk ratios of 1.47-3.90 between trouble falling asleep and coronary events after adjusting for age and various coronary risk factors (combined effect=1.7, p<0.0001). While alternative explanations such as medication use still need to be ruled out, we theorize that a subjective insomniac complaint either may be part of a larger syndrome that includes poor health and depression, or it may be related to continual stressors, reduced slow-wave sleep, and autonomic dysfunction, which increase the risk of heart problems.

Psychosocial and physical correlates of chronic depression.

This study used a case-control design to address differences in psychosocial, physical and clinical profiles between subjects who presented with a chronic index episode of major depression and those who presented with a non-chronic index episode. Subjects were adult patients participating in the Duke University Mental Health Clinical Research Center (MHCRC) for the Study of Depression in Later Life. Cases (N = 88) who reported duration of depressive symptoms lasting > or = 24 months at enrollment were compared to controls (N = 354) who reported symptoms lasting 1-12 months. The groups were compared with respect to selected demographic and clinical variables, physical function deficits, medical comorbidity, social support constructs and number of recent stressful life events. Social support and physical health were more relevant to chronicity of major depressive illness than were severity of illness or family history. Older age (> 60 years) intensified the deleterious effect of recent negative life events and reduced the deleterious effect of functional impairment on chronic major depression. These findings require special emphasis where treatment for chronic major depression is divorced from considerations of the social environment and functional capacity.

Factors associated with paranoid symptoms in a community sample of older adults.

Symptoms of paranoia were found in 9.5% of a community sample of older adults in North Carolina. In cross-sectional analyses, these symptoms were associated most strongly with black race, lower income and education, less exercise, and more depressive symptoms. In longitudinal analysis, paranoid symptoms three years following initial interview were predicted by baseline paranoid symptoms, education and depressive symptoms at the initial interview. In blacks, paranoid symptoms may represent an appropriate response to a hostile environment rather than a psychopathic trait.

Preference for place of death in a continuing care retirement community.

PURPOSE: To describe death-related planning and preferences for place of death among well elders in a community characterized by a low rate of hospital deaths. DESIGN AND METHODS: Cross-sectional prevalence survey of independent-living residents (n = 219) of a continuing-care retirement community (CCRC) in Central North Carolina characterized by a low rate of hospital deaths. RESULTS: Death-related planning played a part in the decision of 40% of residents to move to the CCRC. A majority of residents reported a clear preference for place of death, and a majority of these preferred to die on the CCRC campus. Most residents wanted to discuss their preferences for place of death with their health care provider. Preferences for place of death appear consistent across age cohorts and are relevant to elders' long-term care decisions. IMPLICATIONS: Given the striking discrepancy between patients' preferences for nonhospital deaths and the high prevalence of hospital deaths in the United States, this often-neglected issue should be routinely addressed in end-of-life planning. The CCRC may be a practice model that is particularly compatible with personal preferences for place of death.