Is the tyramine test for depressive illness useful in elderly patients?

There were no significant differences in tyramine sulphate excretion following tyramine ingestion between elderly depressed, demented or control patient groups, in contrast with younger subjects where this test is a trait marker for unipolar endogenous depression. There are inherent problems in urine collection studies in the elderly and the results may have been influenced by the medication that elderly patients have to take for other disorders. This study suggests that the tyramine test is unlikely to be of clinical usefulness in the over 65 age group.     

The functional status of arrhythmia patients in the late period after the radical correction of tetralogy of Fallot

OBJECTIVE: To assess the cognitive performance of elderly patients referred to the memory clinic. DESIGN: The patients were interviewed using the computerised mental state programme, GMS-AGECAT, and assessed on the Cognitive Assessment Scale (CAS) which includes the Elderly Cognitive Assessment Questionnaire (ECAQ) and the Cambridge Memory Test (CMT), modified for Chinese elderly. SUBJECTS: There were 72 Chinese elderly subjects aged 65 years and above, referred to the NUH Memory Clinic in the first year. RESULTS: Only 45 (62.5%) of the 72 subjects were diagnosed to have dementia using DSM III R criteria. There were 25 cases of Alzheimer's Disease and 20 multi-infarct dementia. In the non-demented group, 15 (20.8%) had depression or anxiety disorders and 12 (16.7%), had no mental disorders but had physical illness which could affect memory. There was a highly significant difference in the ECAQ, CMT and CAS scores of demented and non-demented elderly. There was also a significant difference in the cognitive performance of elderly with mild dementia and those with no mental disorder. CONCLUSION: The memory clinic is a useful facility for the diagnosis and management of dementia. The Cognitive Assessment Scale provides a valid and reliable battery of tests for dementia.     

Rate of forgetting in dementia and depression.

Patients with mild dementia of the Alzheimer's type (DAT), patients with major depression, and normal control subjects were examined for rate of forgetting line drawings of common objects after the groups had been equated for acquisition by the variation of stimulus exposure time. Depressed and DAT patients demonstrated learning impairments, but only the DAT group showed rapid forgetting in the first 10 min after learning to criterion. This finding suggests that some form of deficient consolidation contributes to memory loss in DAT but not in depression and implicates the disruption of different psychobiological mechanisms in these disorders. The rate of forgetting paradigm may be clinically useful for distinguishing patients with early DAT from elderly depressed patients with memory deficits. (53 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Elbow valgus stress radiography in an uninjured population

OBJECTIVE: The purpose of this study was to determine if P300 latency is prolonged in geriatric depression and if longer P300 latency and deficits in initiation and errors of perseveration in depressed elderly patients are related to risk factors for vascular disease. METHOD: Geriatric patients with unipolar depression (N = 43) and elderly comparison subjects (N = 24) were assessed for depressive symptoms, cognitive functions, risk factors for vascular disease, and P300 latency. RESULTS: Depressed elderly patients had longer P300 latency than normal elderly subjects. In the depressed patients, P300 latency was related to deficits in initiation and errors in perseveration. Risk factors for vascular disease were associated not only with P300 latency but also with deficits in initiation and errors in perseveration. CONCLUSIONS: Functional impairment of the cortico-striato-pallido-thalamo-cortical pathways from vascular disease, implicated in late-life depressive disorders, may explain not only deficits in initiation and errors in perseveration but also longer P300 latency in depressed elderly patients. These results are preliminary and need further examination with brain imaging and more sensitive neuropsychological measures.     

Cognitive complaints in elderly depressed and pseudodemented patients.

The cognitive complaints of 11 patients with depressive pseudodementia were compared with those of 22 patients with depression alone. Pseudodemented subjects were defined as depressed inpatients showing reversible cognitive impairment as measured by the Mini-Mental State Examination (MMSE); subjects with depression alone had no such impairment. For each group, cognitive complaints were highly correlated with depressive symptoms and were not related to MMSE scores. The pseudodemented group had significantly higher cognitive complaint scores, complaining more of difficulties with concentration and recent memory. Groups did not differ significantly in complaints of difficulties with remote memory. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

MRI signal hyperintensities in geriatric depression

OBJECTIVE: The authors rated periventricular and subcortical signal hyperintensities on magnetic resonance imaging (MRI) scans in elderly patients with depression and in normal subjects with similar demographic features to examine whether such changes discriminate patients with depression from normal subjects and whether they are associated with any clinical variables. METHOD: Two established hyperintensity rating systems were used to compare the MRI brain scans of 48 elderly patients with depression diagnosed according to DSM-III-R with the scans of 39 normal elderly subjects. RESULTS: Elderly depressed patients manifested significantly more severe hyperintensity ratings in the subcortical gray matter than age-matched comparison subjects. Significant differences were not identified between patients with similar current ages and cerebrovascular disease risk who had early-onset or late-onset depression. CONCLUSIONS: These findings support those of neuroimaging studies implicating the basal ganglia in depression and geriatric depression. The data suggest that the relationship observed in some reports between late-onset depression and MRI hyperintensities is most likely a function of cerebrovascular disease risk and age.     

Recent advances in skeletal-muscle-based gene therapy

OBJECTIVE: To determine the sensitivity and specificity of postmortem dementia diagnoses based on a retrospective informant interview by comparison with criterion standard neuropathological diagnoses and the results of previous clinical examinations. SETTING: Three university-based academic research centers. SUBJECTS: Fifty-four deceased elderly persons with Alzheimer disease, another dementing disorder, a neurologic disease resulting in functional impairment but no dementia, or no neurologic disorder. METHODS: Blinded nonclinician interviewers administered the Dementia Questionnaire (DQ) by telephone to informants, typically close relatives, who were familiar with the intellectual and functional status of the subjects before death. Two senior clinicians (LJ.T. and C.K.) rated each DQ for the presence or absence of a dementia syndrome during life and for the specific disorders causing the dementia, if present. Raters were blinded to the neuropathological findings and based their assessments only on data provided by responses to the DQ. Comparison was made with diagnoses based on neuropathological assessment. In most cases, the results of antemortem clinical examinations were also available as a check on the clinical diagnosis of the dementia syndrome. Sensitivity and specificity of the DQ diagnoses were computed, and chance-corrected agreement measures were calculated for the 2 independent DQ raters (LJ.T. and C.K.). RESULTS: Compared with antemortem clinical diagnosis, the average sensitivity of the DQ for the clinical syndrome of dementia was 92.8%, the specificity was 89.5%, and the interrater agreement was 98% (kappa = 0.96). Among 7 subjects with mild dementia (Mini-Mental State Examination score > or = 24 at the last clinical examination), 5 (71%) were correctly identified using the DQ. The DQ correctly indicated the absence of dementia in 8 (80%) of 10 subjects with other neurologic disorders causing functional impairment. Compared with the neuropathological diagnoses, the DQ differentiated Alzheimer disease from other primary causes of dementia with a sensitivity of 89% and a specificity of 72%. The interrater agreement was 93.8% (kappa = 0.85). CONCLUSIONS: Compared with the results of the antemortem clinical examinations, the DQ was sensitive to the presence of dementia, detected most cases of mild dementia, and discriminated dementia from other neurologic disorders causing functional impairment. Compared with the neuropathological diagnoses, the ability of the DQ to differentiate Alzheimer disease from other dementing disorders indicates that it may be useful as a research tool.     

Is the diagnosis of dementia stable over time among elderly immigrant Gujaratis in the United Kingdom (Leicester)?

BACKGROUND: The single largest ethnic elder group in the United Kingdom originates from the Indian subcontinent and their numbers are increasing. METHOD: Elderly Gujarati subjects, with a diagnosis of dementia ascertained during an epidemiological field study in Leicester, were reexamined at a median follow-up interval of 27 months to establish stability of the original diagnosis and cognitive decline. RESULTS: Seven of the original 11 subjects with dementia were alive at the follow-up and they were reexamined by a Gujarati psychiatrist. In six of these seven subjects the diagnosis of dementia was reconfirmed with concomitant cognitive decline on the CAMDEX dementia severity index. Informant history in three of the four original dementia subjects provided evidence of cognitive decline between the original interview and death. CONCLUSION: The diagnosis of dementia in elderly Gujaratis was stable at follow-up with concurrent evidence of decline. This also provided further support for the validity and performance of the Gujarati MMSE in the original study.     

Effect of carbamazepine on agitation in Alzheimer's inpatients refractory to neuroleptics

BACKGROUND: Agitation in Alzheimer's disease remains a principal problem in the clinical management of elderly patients. Neuroleptic medication appears to have modest efficacy in controlling behavioral symptoms in dementia patients. Carbamazepine has been reported to decrease agitation associated with various psychiatric disorders and to reduce neuroleptic side effects. METHOD: In an open prospective study, the effects of carbamazepine on agitation, hostility, and uncooperativeness were investigated in 15 severely demented Alzheimer's inpatients who had failed to respond to prior treatment with neuroleptics. Depending on clinical efficacy and tolerability of carbamazepine treatment, concomitant medication with haloperidol was initiated. Severity of psychopathologic symptoms was assessed by the Brief Psychiatric Rating Scale during the study period of 4 weeks. RESULTS: In 2 subjects, carbamazepine treatment was discontinued because of leukopenia and allergic reactions. A significant improvement in factor scores activation and hostility was observed after 4 weeks. Ten patients received concomitant medication with haloperidol. CONCLUSION: Carbamazepine may be effective in treating agitation in severely demented Alzheimer's inpatients refractory to neuroleptic medication alone. The combination of carbamazepine and haloperidol seems to be promising in clinical management of elderly Alzheimer's patients.     

Moclobemide. An update of its pharmacological properties and therapeutic use

Unlike older monoamine oxidase inhibitors, which irreversibly and nonselectively bind monoamine oxidase (MAO), moclobemide is a reversible and selective inhibitor of the MAO-A isozyme. Moclobemide only weakly potentiates the pressor response induced by tyramine or other indirectly acting sympathomimetics; therefore, there is no need to avoid dietary tyramine or over-the-counter decongestants with moclobemide as there is with older MAO inhibitors. Recent clinical trials and meta-analyses have confirmed the efficacy of moclobemide in the treatment of depressive disorders. Moclobemide has been shown to have similar efficacy to tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs) and nonselective, irreversible MAO inhibitors. Long term follow-up studies of 6 to 12 months' duration have demonstrated that the antidepressant efficacy of moclobemide is maintained. Moclobemide, given alone or in combination with another antidepressant, has shown some efficacy in patients with refractory depression; however, comparative trials are required to confirm these findings. Data are also available to show clinical efficacy of moclobemide in the management of social phobia. Comparative studies have established that moclobemide is better tolerated at therapeutic dosages and has less toxicity in overdose than TCAs and nonselective, irreversible MAO inhibitors. Moclobemide lacks the anticholinergic, sedative and cardiovascular effects associated with many of the older antidepressants. Compared with SSRIs, moclobemide has a similar overall tolerability, although it tends to cause fewer gastrointestinal effects than the SSRIs and has not been reported to interfere with sexual function. In summary, recent data which confirm and extend its comparative therapeutic efficacy and low potential for adverse effects have established moclobemide as an effective treatment in depressive disorders. The drug is also effective in patients with a primary diagnosis of social phobia. Its lack of adverse anticholinergic, cardiovascular, cognitive and psychomotor effects makes moclobemide a particularly useful option in the elderly or patients with cardiac disease.     

Outcome of the depressed elderly living in the community in Liverpool: a 5-year follow-up

BACKGROUND: Comparatively little is known about the long-term natural history of depressive disorders in the elderly living in the community. This is a follow-up of a subsample of the Continuing Health in the Community study random sample of the elderly population living in Liverpool. METHODS: The investigators followed up 120 cases of depression identified by a semi-structured interview schedule (GMS) for a period of 5 years. A similar number of other subjects defined as subcases of depression, other cases of mental illness and a random selection of non-cases were also included. RESULTS: The 5-year outcome for the cases of depression was worse than the outcome of the non-cases (relative mortality risk of 2.1, 95% confidence interval 1.1 to 3.9). Thirty-four per cent of the cases of depression died and 28% had dropped out during the follow-up. Of the 46 cases of depression who had a complete follow-up, 22% recovered from their symptoms, 30% were found to be AGECAT cases at one of the three follow-up waves, 24% were AGECAT cases at two of the three follow-up waves and the remaining 24% were AGECAT cases at each follow-up wave. Fifteen per cent of the surviving cases of depression were organic cases at the follow-up. Their anxiety comorbid state and depression score were identified as predictors of poor outcome. CONCLUSION: The findings of this study indicate that depressive disorders (most of which were untreated) found in the elderly community have a poor prognosis.     

Depression of young and elderly patients

OBJECTIVE: To compare the presentation and outcome of depression between young and elderly patients. DESIGN: The clinical presentation, treatment and outcome of 47 young patients (21 to 64 years) were compared with 58 elderly (65 years and older) patients admitted to a general hospital psychiatric ward for the treatment of depressive disorders (based on ICD-10). SUBJECTS: There was no significant difference between the sexes in each age group. The majority of the elderly were either widowed (36%) or married (53%) while 45% of the young were single and 51% married. Seventy per cent of the elderly had retired while 64% of the young were in full-time employment. Most patients lived with their families (87% young and 96% elderly). All but one elderly suffered at least one physical disorder with two-thirds having two or more physical disorders; this contrasts greatly to young patients who were physically healthier (p < 0.001). RESULTS: In clinical presentation and symptomatology, the young patients had significantly more suicide ideation (p < 0.003) and psychomotor retardation (p < 0.001) but there was no difference in suicidal attempt, delusion, hallucination or agitation. More young patients (36%) had a past psychiatric illness (often depressive disorders) than elderly patients (8%) (p < 0.001), more elderly patients (88%) were treated with antidepressants than the young patients (62%) (p < 0.002). At one year follow-up, more elderly patients (46%) recovered compared with the young patients (23%) (p < 0.05). CONCLUSION: There were some differences in the symptomatology of depression between young and elderly patients, but the prognosis was better for elderly patients.     

Auditory event related potentials in major depression: prolonged P300 latency and increased P200 amplitude

BACKGROUND: Some studies have shown disturbances in auditory event related potentials (AERPs) in patients with major depression. METHODS: In this exploratory study, the late AERP components, N100 (latency), P200 (amplitude and latency) and P300 (amplitude and latency) were recorded in 68 subjects, i.e. 39 major depressed subjects, with (n=4) or without (n=35) cognitive deterioration, 18 patients with Alzheimer's dementia (SDAT) and 11 normal volunteers. Twenty-five major depressed patients had repeated measurements of AERPs both before and after treatment with antidepressants. RESULTS: Major depressed subjects without cognitive deterioration had significantly higher P300 latency and P200 amplitude than normal volunteers. SDAT patients and major depressed patients with cognitive impairment had a significantly higher P300 latency than depressed patients without cognitive impairment. In the latter, no significant alterations in any of the AERP components upon subchronic treatment with antidepressants were recorded. Nonresponders to antidepressant therapy had significantly higher pretreatment P300 latency and P200 amplitude than responders to treatment (P=0.006) and normal volunteers (P=0.0004). CONCLUSIONS: The findings may suggest that delayed P300 latency as well as increased P200 amplitude accompany major depression and may predict a nonresponse to subsequent antidepressive therapy.     

Poroid hidradenoma. A case presentation

There is no study indicating that informant-derived information on dementia and depression (i.e. family history information) is equivalently valid for first-degree relatives and for index subjects (i.e. patients and control subjects). However, this unproven assumption is the basis for the frequent, possibly inappropriate, use of instruments validated for patients and control subjects in family studies which focus on frequencies of psychiatric disorders in first-degree relatives. Consequently, there is a need to compare the validity of family history information for both disorders in index subjects and their first-degree relatives. Validity was assessed by comparison of family history information for dementia and depression with interview-derived diagnoses in 75 index subjects and 195 age-matched first-degree relatives. The validity of informant-derived information varied for different disorders, i.e. dementia and depression, and different samples, i.e. index subjects and first-degree relatives. In agreement with the study hypothesis, the sensitivity of surrogate information on dementia was significantly reduced in first-degree relatives in comparison with index subjects. In contrast, the sensitivity to detect depression was equivalent in subjects and in relatives. The results indicate the necessity to assess the validity of the psychiatric diagnoses of interest in the sample of interest, e.g. dementia or depression in first-degree relatives of patients and of control subjects. Observations in selected samples, i.e. subjects treated, hospitalised and/or autopsied, cannot be generalised to first-degree relatives in family studies.     

The trauma patient: open hospital choice?

Mental-health service utilization among elderly people has been shown to be low relative to younger age groups. This study was done to determine the current proportion of elderly persons served in a university-affiliated psychiatry outpatient clinic, and to better characterize elderly patients who receive specialized mental-health care in this setting. The proportion of visits from elderly patients (aged 60 and over) was found to be 16%. Demographic and clinical characteristics of a sample of 140 consecutive geriatric patients evaluated at the clinic were obtained. The data revealed that the patients had a mean age of 74.7+/-7.5 (SD) years, and were mostly female (72.1%) and white (78.6%). Surprisingly, the age distribution was found to be bell shaped, with a small upper tail. The three most prevalent psychiatric diagnoses were depression (56.4%), dementia (35.7%), and substance use disorder (20%). Overall, 59.3% of geriatric patients had a history of prior psychiatric treatment. Females were significantly more likely than males to have a psychiatric history (69.3% vs. 33.3%, P = .0001). Among patients with a psychiatric history, females were more likely to have a current diagnosis of major depression (P = .0006), while males were more likely to have a current substance use disorder (P = .03). The prevalence of dementia increased with each successive decade above 60, while the occurrence of bipolar and adjustment disorders was confined to younger geriatric patients. Elderly patients receiving psychiatric treatment in the clinic thus formed a heterogeneous group. Gender, age, and presence of a psychiatric history were all associated with differences in prevalence and distribution of various mental disorders in this geriatric psychiatry outpatient clinic.     

Clinical tests of memory in dementia, depression, and healthy aging.

In Study 1, 20 elderly adults (mean age 72.7 yrs) with primary degenerative dementia or major depression were compared to 10 healthy aged controls on 3 tests of learning and memory: the Benton Visual Retention Test; a paired-associate learning test; and the object–memory evaluation (OME) developed by P. A. Fuld (1981). The sharpest distinction in performance among the groups was observed on the OME, and discriminant equations based on this test correctly classified at least 90% of the Ss. Study 2 applied the classification rules derived in the 1st investigation to an unselected series of 25 63–86 yr old geropsychiatry inpatients referred for neuropsychological evaluation. There was agreement between memory test classification and general categories of clinical discharge diagnosis (organic vs functional) for 21 of the Ss and with status at follow-up approximately 18 mo later. Predictive value computations suggested that the OME is more accurate in confirming true dementia than in detecting dementia syndromes associated with functional disorders. (45 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Selective reminding procedure in depression and dementia.

Patients with mild dementia of the Alzheimer's type (DAT), patients with major depression, and normal elderly control subjects were administered a verbal learning task using the selective reminding procedure. Depressed patients were impaired on total recall and the proportion of items retained from one trial to the next without reminding and did not benefit from imagery in retaining items over consecutive trials. The DAT patients were impaired on all measures derived from the test, including storage and recognition memory. With the exception of the ability to benefit from imagery, all of the measures distinguished depressed and mild DAT patients. These findings are consistent with deficient encoding in DAT and performance deficits as a function of effortful cognitive processing in depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Social phobia, avoidant personality disorder and atypical depression: co-occurrence and clinical implications

BACKGROUND: Increasing attention has been directed in recent years to the detection and treatment of psychiatric co-morbidity among depressed individuals. The overlap of social phobia (SP) and avoidant personality disorder (APD) has been well recognized and a relationship between these disorders and depression has been suggested. METHODS: The pattern and clinical implications of co-morbidity of SP and APD with major depressive disorder (MDD), diagnosed by DSM-III-R criteria, were studied among 243 out-patients presenting with depression. RESULTS: Overall, 26.7% of adults in our sample with MDD met criteria for SP and 28.4% for APD. Almost two-thirds of depressed adults meeting criteria for social phobia or avoidant personality disorder met criteria for both (SP+APD). Depressed adults who met criteria for both SP+APD exhibited a significantly higher proportion of atypical depression (54.8%) compared with those with neither SP nor APD (31.1%). Among depressed patients, the co-occurrence of SP with APD was also associated with an earlier age of onset of MDD, a greater number of comorbid Axis I diagnoses, and greater impairment of social adjustment and assertiveness. CONCLUSIONS: Results confirm the overlap of SP and APD in a depressed population and the high prevalence of these disorders in MDD. They suggest that depressed individuals with both SP and APD but not SP alone are at particularly high risk for atypical depression and for social dysfunction in excess of that caused by a current major depression.     

The syndrome of depressive depersonalization

Nineteen patients (9 men, 10 women aged 22--38 years) with depressions were examined. The phenomena of anesthesia of ideatoric functions dominated in clinical picture of such depression. This depression is defined as the depression of estrangement. Psychopathologic differentiation of mental estrangement in the structure of depression and in similar disorders of self-consciousness which were formed in depressions under conditions of "transitional syndrome" (according to G.Gross) is outlined. This syndrome is characterised by irreversible negative disorders of "defective depersonalization". The following signs permit to distinguish depression of estrangement from "transitional syndrome": partiality of the estrangement's phenomenon; connection between psychopathologic formations and pathology of imagination (figurative expressiveness, demonstrativity, lability to psychogenic and medical actions); conformity of the syndrome's structure and characteristics of premanifested personality's structure (combination of hyperthymic features with histrionic and/or narcissic ones). "Apperceptive anesthesia" is suggested for designation of the variant of the depression described.     

The effect of gender and age at onset of depression on mortality

BACKGROUND: Depression has a marked negative impact on geriatric patient mortality and morbidity. The risk factors and exact reasons for these effects are not well understood. METHOD: Seeking to better define the factors, we retrospectively analyzed the effects of gender and age at onset of affective disorder in a naturalistic study of 192 geriatric patients consecutively admitted to a large midwestern tertiary care center between 1980 and 1987 for the treatment of unipolar depression. RESULTS: After controlling for age at index admission, patients with an onset of depression before age 40 suffered significantly (p < .05) less mortality in follow-up than those with onset after age 40. When effects of gender are examined, the effects of age at onset are most profound in women, with a threefold increase in the rate of death in the cohort with age at onset of depression after 70 years when compared to those with onset before age 40. CONCLUSION: These results and those of others suggest that depressed elderly women with no previous history of affective disorder are at a markedly increased risk compared with elderly women with a history of affective illness for morbidity and mortality and that a significant proportion of elderly depressed patients are admitted to a psychiatric hospital for a depression that is secondary to serious medical illness.