Depression without sadness: functional outcomes of nondysphoric depression in later life

OBJECTIVES: We hypothesized that depressive symptoms not meeting full standard criteria for Major Depression would be associated with significant functional impairment among older adults over the course of a 13-year follow-up interval. Specifically, we developed criteria for a form of depression whose core symptoms did not include sadness or dysphoria. DESIGN: Population-based 13-year follow-up survey. SETTING: Community-dwelling adults living in East Baltimore in 1981. PARTICIPANTS: Subjects were the 1612 participants of the Baltimore sample of the Epidemiologic Catchment Area Program aged 50 years and older at the initial interview in 1981. MEASUREMENTS: The subjects were sorted into four categories based on their responses at baseline: (1) persons meeting standard criteria for Major Depression; (2) persons meeting alternative criteria for depression with dysphoria or (3) without dysphoria; and (4) a comparison category of persons not meeting any criteria for depression ("noncases"). The mortality and functional status of each group were compared after a 13-year follow-up interval. RESULTS: Compared with non-cases, participants aged 50 years and older who reported depressive symptoms but who denied sadness or dysphoria (nondysphoric depression) were at increased risk for death (relative risk (RR) = 1.70; 95% confidence interval (CI) (1.09, 2.67)), impairment in activities of daily living (RR = 3.76; 95% CI (1.73, 8.14)), impairment in instrumental activities of daily living (RR = 5.07; 95% CI (2.24, 11.44)), psychologic distress (RR = 3.68; 95% CI (1.47, 9.21)), and cognitive impairment (RR = 3.00; 95% CI (1.31, 6.89)) after a 13-year follow-up interval. The findings were not wholly explained by potentially influential baseline characteristics such as age, education, selected comorbid medical conditions, and functional status. CONCLUSION: Among adults aged 50 years and older, nondysphoric depression may be as important as Major Depression in relation to the development of functional disability and other long-term outcomes.     

Center for Epidemiologic Studies Depression Scale (CES-D) as a screening instrument for depression among community-residing older adults.

The efficacy of the Center for Epidemiologic Studies Depression Scale (CES-D) as a screener for clinical depression was examined in a sample of 1.005 community-residing adults (age range?=?50–96). Presence of a depressive disorder was determined by diagnostic interview. Analyses revealed that neither age, gender, cognitive impairment, functional impairment, physical disease, nor social desirability had a significant negative effect on the psychometric properties or screening efficacy of the CES-D. These results indicate that there was no significant degradation in the ability of the CES-D to screen for depression among community-residing elderly adults. This conclusion must be tempered by the fact that the sample did not include participants with the more disabling forms of cognitive or functional impairment and physical illness. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Perceived burdensomeness and suicide ideation in older adults.

Older adults have the highest risk of death by suicide in the United States. Improving our understanding of the factors that lead to increased risk of suicide in older adults will greatly inform our ability to prevent suicide in this high-risk group. Two studies were conducted to test the effect of perceived burdensomeness, a component of the interpersonal-psychological theory of suicide (Joiner, 2005), on suicide ideation in older adults. Further, gender was examined as a moderator of this association to determine if perceived burdensomeness exerted a greater influence on suicide ideation in males. The results of these studies suggest that perceived burdensomeness accounts for significant variance in suicide ideation, even after predictors such as depressive symptoms, hopelessness, and functional impairment are controlled. Gender did not moderate the association. The implications of these findings for treatment of older adults with suicide ideation and elevated suicide risk are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Factors associated with institutionalization of older people in Canada: testing a multifactorial definition of frailty

OBJECTIVES: To test a model of frailty by examining factors associated with institutionalization of older people in Canada; to assess whether diagnostic data provided information about risk beyond that provided by data on functional capacity and demographic variables. METHODS: Cross-sectional study of 1258 institutional subjects and 9113 community-dwelling older adults from the Canadian Study of Health and Aging. RESULTS: Multiple logistic regression analysis showed that female gender, being unmarried, absence of a caregiver, presence of cognitive impairment (including all types of dementia), functional impairment, diabetes mellitus, stroke, and Parkinson's disease were independently associated with being in a long-term care facility. CONCLUSION: Frailty appears to be a multidimensional construct, and not simply a synonym for dependence in Activities of Daily Living. Studies of health outcomes in older people should include diagnostic data as well as demographic information and data on functional capacity.     

Different storage and retrieval deficits in normal aging and mild cognitive impairment: A multinomial modeling analysis.

The authors compared patients with mild cognitive impairment with healthy older adults and young control participants in a free recall test in order to locate potential qualitative differences in normal and pathological memory decline. Analysis with an extended multitrial version of W. H. Batchelder and D. M. Riefer's (1980) pair-clustering model revealed globally decelerated learning and an additional retrieval deficit in patients with mild cognitive impairment but not in healthy older adults. Results thus suggest differences in memory decline between normal and pathological aging that may be useful for the detection of risk groups for dementia, and they illustrate the value of model-based disentangling of processes and of multitrial tests for early detection of dementia. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Impairment in risk-sensitive decision-making in older suicide attempters with depression.

Suicidal behavior is a potentially lethal complication of late-life depression. In younger adults, suicide has been linked to abnormal decision-making ability. Given that there are substantial age-related decreases in decision-making ability, and that older adults experience environmental stressors that require effective decision-making, we reasoned that impaired decision-making may be particularly relevant to suicidal behavior in the elderly. We thus compared performance on a probabilistic decision-making task that does not involve working memory (“Cambridge Gamble Task”) in four groups of older adults: (1) individuals with major depression and a history of suicide attempt (n = 25), (2) individuals with major depression with active suicidal ideation but no suicide attempt (n = 13), (3) individuals with major depression without suicidality (n = 35), and (4) nondepressed control subjects (n = 22). There was a significant effect of group on quality of decision-making, whereby the suicide attempters exhibited poorer ability to choose the likely outcome, compared with the nonsuicidal depressed and nondepressed comparison subjects. There were no group differences in betting behavior. The suicide attempters differed in several aspects of social problem-solving on a self-report scale. Quality of decision-making was negatively correlated with the score on the impulsive/careless problem-solving subscale. These data suggest that older suicide attempters have a deficit in risk-sensitive decision-making, extending observations in younger adults. More specifically, older suicide attempters seem to neglect outcome probability and make poor choices. These impairments may precipitate and perpetuate suicidal crisis in depressed elders. Identification of decision-making impairment in suicidal elders may help with designing effective interventions. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

A longitudinal analysis of anxiety and depressive symptoms.

The authors modeled depressive and anxiety symptom data from 1,391 participants in a longitudinal study of middle-aged and older Swedish twins (M age?=?60.9 years, SD?=?13.3). Although anxiety and depression were highly correlated, a model with distinct Anxiety and Depression factors fit the data better than models with Positive and Negative Affect factors or a single Mental Health factor. Lack of well-being was associated with anxiety rather than depression. Over two 3-year intervals, anxiety symptoms led to depressive symptoms, but the relationship was not reciprocal. Anxiety symptoms were more stable than depression. These findings provide additional support for the idea that anxiety symptoms may reflect a personality trait such as neuroticism more than do depressive symptoms and suggest that low positive affect may not be as specific to depression among older adults as in younger people. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Angiocardiographic digital still images compressed via irreversible methods: concepts and experiments

OBJECTIVE: Primary care occupies a strategic positive in the evaluation, treatment, and prevention of the mental disturbances of later life. This article highlights four themes that are crucial to understanding mental disturbances among older adults: 1) subsyndromal depression, 2) coexisting depression and anxiety, 3) comorbidity of depression and chronic medical conditions, and 4) risk factors for cognitive impairment. METHOD: The literature was selectively reviewed for each theme to ask the central question, "What can primary care physicians learn about mental disturbances of their older patients from epidemiologic and community studies?" RESULTS: The primary care setting itself is an important venue for an examination of aging issues and mental health. Workers in the "middle ground of psychiatric epidemiology"--primary health care--have not yet reached a full appreciation for the value of research in the primary care setting for enhancing our understanding of the mental disturbances of late life, and how these intersect with other salient factors. CONCLUSIONS: Primary care physicians and others who work in primary care should advocate for further mental health integration and research in primary care. Research is needed that will lead to new ways of maximizing the health and quality of life of older adults and their families.     

Prevalence of depressive symptoms among rural elderly: Examining the need for mental health services.

Reexamined the prevalence of depressive symptoms among 1,724 rural, noninstitutionalized older adults (aged 59–99 yrs) and documented the need for mental health services as they relate to depression and potential barriers to receiving needed services. A telephone survey was conducted in North Dakota, with a random sample drawn from each of 8 human service districts. Instruments included the Geriatric Depression Scale and the CAGE. Results indicate that the prevalence of depression was relatively low. Controlling for potential alcohol abuse, cognitive impairment, and medical problems, the study found that 5% of older adults reported current depressive symptomatology. When using a cutoff score that is likely to correspond to a diagnosis of major depression, the study found a prevalence rate of 1.6%. Of those reporting significant levels of depression, only 27.6% were currently being treated for an emotional problem. The survey data suggested that cost, transportation, and concern about stigma are not major barriers to receiving needed mental health services. Rather, lack of awareness of available services and a lack of routine contact with mental health service providers are important factors that limit service utilization. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Longitudinal relationships between depressive symptoms and health in normal older and middle-aged adults.

Comorbidity between health and depression is salient in late life, when risk for physical illness rises. Other community studies have not distinguished between the effects of brief and long-standing depressive symptoms on excess morbidity and mortality. S. Cohen and M. S. Rodriguez's (1995) differential hypothesis of pathways between depression and health was used to examine the relationships between health and depression in a prospective probability sample of 1,479 community-resident middle-aged and older adults. Findings suggest that different durations of depressive symptoms have different relationships to health. Health had an impact on short-term increases in depressive symptoms, but depressive symptoms had a weaker impact on health. The reciprocal impact was indistinguishable from the health influence on depression. In contrast, longer term depressive symptoms had a clear impact on health. The results imply that physical illness can affect depressive states; depressive traits but not states can affect illness. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Is the apolipoprotein e genotype a biomarker for mild cognitive impairment? Findings from a nationally representative study.

Objective: Although the ε4 allele of the apolipoprotein E (APOE) genotype is a known risk factor for Alzheimer's dementia (AD), prior findings on whether it is also a risk factor for mild cognitive impairment (MCI) have been inconsistent. We tested two contrasting explanations: (a) an ε4-AD specificity hypothesis, and (b) a measurement insensitivity hypothesis. Method: The frequency of the ε4 allele was investigated in older adults (mean age > 70) with various types of cognitive impairment (including MCI) and various types of dementia (including AD) with the aging, demographics, and memory study (ADAMS) of the National Institute on Aging's Health and Retirement Study (HRS). The ADAMS controls sources of Type I and Type II error that are posited in the ε4-AD specificity hypothesis and the measurement insensitivity hypothesis, and it is the only nationally representative data set on aging and cognitive impairment. Results: ε4 was a reliable predictor of MCI, with a frequency of 32% in MCI subjects versus 20% in healthy control subjects. This link was specific to MCI because ε4 was not a risk factor for other forms of cognitive impairment without dementia. Conclusions: The results support the measurement insensitivity hypothesis rather than the ε4-AD specificity hypothesis and are consistent with recent research showing modest reductions in cognitive performance among normal functioning ε4 carriers. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Adapting interpersonal psychotherapy for older adults at risk for suicide: Preliminary findings.

We report preliminary findings of the first-ever study testing a 16-week course of interpersonal psychotherapy (IPT) modified for older outpatients at elevated risk for suicide. Participants were referred from inpatient and outpatient medicine and mental health services. Psychotherapy sessions took place in a therapist’s office in a teaching hospital. Twelve adults 60 years or older (M = 70.5, SD = 6.1) with current thoughts of suicide (suicide ideation), a wish to die (death ideation), or with recent self-injurious behavior were recruited into weekly sessions of IPT; 1 participant was subsequently excluded due to severe cognitive impairment. Participants completed measures of suicide ideation, death ideation, and depressive symptom severity at pretreatment, midtreatment, posttreatment, and at 3-month follow-up periods, and measures of therapeutic process variables. Preliminary findings of this uncontrolled pretreatment/posttreatment study support the feasibility of recruiting and retaining older adults at risk for suicide into psychotherapy research and suggest that adapted IPT is tolerable and safe. Findings indicate a substantial reduction in participant suicide ideation, death ideation, and depressive symptoms; controlled trials are needed to further evaluate these findings. We discuss implications for clinical care with at-risk older adults. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Model stability of the 15-item Geriatric Depression Scale across cognitive impairment and severe depression.

The 15-item Geriatric Depression Scale (GDS) is used in a wide variety of clinical and research settings. The study's purpose was to further establish the validity of the 15-item GDS by exploring the underlying factor structure in a healthy, nondemented sample of older adults and then analyzing whether this factor structure remained stable across a sample of demented individuals and a sample of individuals with a history of depression 6 months after discharge from an inpatient psychiatric setting. A 2-factor model fit the data best in the exploratory analyses. The 2 factors, Life Satisfaction and General Depressive Affect, found in the nondemented sample (r = .39) remained stable across cognitive impairment (r = .12) but merged into a 1-factor model in the psychiatric sample (r = .93). The results indicate that nondepressed older adults with poor life satisfaction may be identified as depressed on screening instruments such as the 15-item GDS. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Metabolism of an anionic fluorescent dye, 1-anilino-8-naphthalene sulfonate (ANS) by rat liver microsomes

OBJECTIVE: To examine the association between chronic illness and functional status change during a 3-year period in older people enrolled in an in-home comprehensive geriatric assessment (CGA) and preventive care program. DESIGN: Secondary analysis of data from a longitudinal cohort study. SETTING: Santa Monica, California. PARTICIPANTS: Two hundred two community-dwelling older persons (mean age at baseline was 81 years, 70% were women, and 72% reported good health) randomized to the intervention group in a trial of in-home comprehensive geriatric assessment and preventive care. MEASUREMENTS: We studied 13 common chronic illnesses/conditions determined clinically from an annual comprehensive evaluation by gerontologic nurse practitioners (GNPs) in consultation with study geriatricians. These target conditions included hypertension, osteoarthritis, coronary artery disease, obesity, undernutrition, urinary incontinence, sleep disorders, falls, gait/balance disorders, hearing and vision deficits, depression, and unsafe home environment. The dependent variable was functional change as measured by instrumental activities of daily living (IADL) and basic activities of daily living (BADL) assessed at baseline and annually for 3 years by independent research personnel. Potential confounding variables, including comorbid conditions and other subject characteristics, were controlled for in the analyses. RESULTS: Although functional status was similar at baseline, the presence of certain target conditions in this sample was associated significantly with functional decline in IADL and BADL during the 3-year period. Four conditions (gait/balance disorders, depression, unsafe home environment, and coronary artery disease) were associated with significant declines in IADL, and four conditions (gait/balance disorders, depression, hypertension, and urinary incontinence) were associated with significant declines in BADL. Conversely, subjects with obesity had no significant change in IADL or BADL throughout the study period and had less decline in IADL compared with nonobese subjects. CONCLUSIONS: Certain chronic conditions, particularly gait/balance disorders and depression, are associated with significant decline in functional status in older persons who receive CGA. These findings may help identify older persons at risk for greatest functional decline despite participation in CGA and may also suggest the need for more effective intervention strategies in these individuals.     

Differences in psychosocial and health correlates of major and minor depression in medically ill older adults

OBJECTIVES: To compare the differences in correlates of different levels of depression in medically ill hospitalized older adults. DESIGN, SETTING, AND PARTICIPANTS: A consecutive series of 542 patients aged 60 or older admitted to the medical inpatient services of Duke Hospital underwent a structured psychiatric evaluation administered by a psychiatrist. MEASUREMENT: A wide range of demographic, social, psychiatric, and physical health data were collected, and associations with major and minor depression were assessed. RESULTS: Compared with patients without depression, those with major depression were more likely to have a history of prior episodes of depression, higher dysfunctional attitude scores, greater overall severity of medical illness, cognitive impairment, and symptoms of pain or other somatic complaints. Specific medical diagnosis was less important a predictor of major depression than overall severity of medical illness. Compared with patients without depression, those with minor depression were more likely to report non-health-related stressors during the year before hospital admission, have a diagnosis of immune system disorder, and have greater severity of medical illness. When major and minor depression were compared directly, on the other hand, no significant differences were observed except for history of depression, and that relationship was weak and present only when the etiologic approach to diagnosis was used. CONCLUSION: During hospital admission, certain psychosocial, psychiatric, and physical health characteristics of older medical patients place them at high risk for different levels of depression. Patients with major and minor depression resemble each other more than they do patients without depression. These findings may help clinicians better understand the causes of different types of depression in this setting and lead to improved diagnosis and treatment.     

Age-cohort differences in treating symptoms of mental illness: A process approach.

Examines age-cohort differences in conceptually organizing, observing, and responding to unclustered symptoms of mental illness. Older (M?=?70.8) and younger (M?=?19.9) adults sorted symptoms of depression, schizophrenia, and age-associated changes into similarity groupings. Hierarchical cluster analysis showed that both older and younger adults sorted the statements similarly, although labels given for depressive symptoms differed across groups. Participants then reported which symptoms they had observed within their families and listed what actions were taken. Age groups showed significant differences in symptom reporting, with older individuals observing depressive symptoms less frequently. There were small differences in the kinds of actions reported. These results suggest that differences in help-seeking behavior for mental illness may be explained by differences in the way symptoms are observed by younger and older cohorts. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Age-related differences and similarities in dual-task interference.

Differences between younger adults (mean age, 20.7 years) and older adults (mean age, 72.7 years) in dual-task performance were examined in 7 experiments in which the overlap between 2 simple tasks was systematically varied. The results were better fit by a task-switching model in which age was assumed to produce generalized slowing than by a shared-capacity model in which age was assumed to reduce processing resources. The functional architecture of task processing appears the same in younger and older adults. There was no evidence for a specific impairment in the ability of older adults to manage simultaneous tasks. There was evidence for both input and output interference, which may be greater in older adults. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Mortality over four years in SHEP participants with a low ankle-arm index

OBJECTIVES: To assess the risk of total and cardiovascular mortality in older adults with systolic hypertension and with a low ankle-arm index (AAI) as a marker of subclinical peripheral arterial disease (PAD). DESIGN: Prospective observational study PARTICIPANTS: A subgroup of 1537 participants in the Systolic Hypertension in the Elderly Program (SHEP) were screened for lower extremity arterial disease using the AAI. Participants were evaluated at 4 years to determine vital status and cause of death. Total and cardiovascular disease (CVD) mortality rates were assessed in relationship to clinical CVD at baseline, cardiovascular risk factors and the presence of a low AAI (subclinical PAD). RESULTS: Total mortality rates increased as the AAI decreased in those with and without clinical CVD at baseline. In those without clinical CVD at baseline, the presence of an AAI < or = .9 was associated with an age-adjusted relative risk (RR) of 3.00 for total mortality in men and 2.67 in women. Results were similar for CVD mortality and persisted after adjustment for cardiovascular risk factors including the presence of an abnormal electrocardiogram. CONCLUSIONS: A low ankle arm-index predicted a two to three-fold increase in total and cardiovascular mortality in older adults with systolic hypertension of risk for incident cardiovascular disease. In this study of older adults with systolic hypertension, 19.7% of the participants had subclinical PAD. Risk factor modification could be targeted to older adults based on markers of asymptomatic atherosclerosis.