Lawrence S. Mayer

Reduced incidence of AD with NSAID but not H2 receptor antagonists: The Cache County Study

Background Previous analyses from the Cache County (UT) Study showed inverse associations between the prevalence of AD and the use of nonsteroidal anti-inflammatory drugs (NSAID), aspirin compounds, or histamine H2 receptor antagonists (H2RA). The authors re-examined these associations using data on incident AD. Methods In 1995 to 1996, elderly (aged 65+) county residents were assessed for dementia, with current and former use of NSAID, aspirin, and H2RA as well as three other “control” medication classes also noted. Three years later, interval medication histories were obtained and 104 participants with incident AD were identified among 3,227 living participants. Discrete time survival analyses estimated the risk of incident AD in relation to medication use. ResultsAD incidence was marginally reduced in those reporting NSAID use at any time. Increased duration of use was associated with greater risk reduction, and the estimated hazard ratio was 0.45 with ≥2 years of exposure. Users of NSAID at baseline showed little reduction in AD incidence, regardless of use thereafter. By contrast, former NSAID users showed substantially reduced incidence (estimated hazard ratio = 0.42), with a trend toward greatest risk reduction among those with extended exposure. Similar patterns appeared with aspirin but not with any other medicines examined. Conclusions Long-term NSAID use may reduce the risk of AD, provided such use occurs well before the onset of dementia. More recent exposure seems to offer little protection. Recently initiated randomized trials of NSAID for primary prevention of AD are therefore unlikely to show effects with treatment until participants have been followed for several years.

Incidence of AD may decline in the early 90s for men, later for women The Cache County study

Objectives: To characterize the incidence of AD among the elderly population of Cache County, UT, noted for its longevity and high response rates; to explore sex differences; and to examine whether AD incidence plateaus or declines in extreme old age. Methods: Using a multistage screening process in 1998 and 1999, and reexamining 122 individuals who had been identified 3 years earlier as cognitively compromised but not demented, the authors found 185 individuals with incident dementia (123 with AD) among 3,308 participants who contributed 10,541 person-years of observation. Adjusting for nonresponse and screening sensitivity, the authors estimated the incidence of dementia and of AD for men and women in 3-year age intervals. Multivariate discrete time survival analysis was used to examine influences of age, sex, education, and genotype at APOE, as well as interactions of these factors. Results: The incidence of both dementia and AD increased almost exponentially until ages 85 to 90, but appeared to decline after age 93 for men and 97 for women. A statistical interaction between age and the presence of two APOE-ε4 alleles indicated acceleration in onset of AD with this genotype; the interaction of age and one ε4 suggested more modest acceleration. A statistical interaction of sex and age indicated greater incidence of AD in women than in men after age 85. Conclusions: The incidence of AD in the Cache County population increased with advancing age, but then peaked and declined among the extremely old. The presence of APOE-ε4 alleles accelerated onset of AD, but did not appreciably alter lifetime incidence apparent over a span of 100 years.

The short-term impact of two classroom-based preventive interventions on aggressive and shy behaviors and poor achievement☆

Abstract Two classroom-based preventive interventions were carried out on an epidemiologically defined, varied population of children in a metropolitan area in the United States. This is a report of the short-term impact and specificity of the two interventions from fall through spring of first grade. The first intervention, the Good Behavior Game, was aimed at reducing aggressive behavior and shy behavior. Aggressive behavior has been shown to be an important developmental antecedent in first grade of later delinquency and heavy drug use, particularly when coupled with shy behavior. The second intervention, Mastery Learning, was designed to improve poor reading achievement, which has been shown to be an antecedent for later depressive symptoms, as well as a correlate of aggressive and shy behaviors. Each of the two interventions had a significant and very specific impact only on its own proximal target(s). In addition to main effects, there were theoretically important variations of impacts among subgroups of children. The Good Behavior Game appeared to have a greater impact in reducing aggressive behavior among the more aggressive children. The nature of the impact of Mastery Learning differed by gender, with female high achievers benefiting more from the intervention than female low achievers, and male low achievers benefiting more than male high achievers. Developmental epidemiologically based preventive trials provide a powerful means of addressing questions about etiology and development, particularly around the issue of the malleability of developmental processes. Important questions that future work could test are whether achievement is improved by improving aggressive or shy behaviors and whether aggressive or shy behaviors are improved by improving achievement. Such investigation would inform our understanding of their etiology.

Developmental epidemiologically based preventive trials: Baseline modeling of early target behaviors and depressive symptoms

Describes a conceptual framework for identifying and targeting developmental antecedents in early childhood that have been shown in previous work to predict delinquency and violent behavior, heavy drug use, depression, and other psychiatric symptoms and possibly disorders in late adolescence and into adulthood. Criteria are described that guided choices of targets for two epidemiologically based, randomized preventive trials carried out in 19 elementary schools in the eastern half of Baltimore, involving more than 2,400 first-grade children over the course of first and second grades. Baseline models derived from the first of two cohorts show the evolving patterns of concurrence among the target antecedents. The central role of concentration problems emerged. From Fall to Spring in first grade, concentration problems led to shy and aggressive behavior and poor achievement in both genders and to depressive symptoms among girls. There was evidence for reciprocal relationships in girls. For example, depressive symptoms led to poor achievement in both girls and boys, whereas poor achievement led to depressive symptoms in girls but not boys, at least over the first-grade year. These results provide important epidemiological data relevant to the developmental paths leading to the problem outcomes and suggest preventive trials.

Depressive symptoms over first grade and their response to a developmental epidemiologically based preventive trial aimed at improving achievement

This article is about the course of depressive symptoms during a classroom-based randomized preventive field trial aimed at improving reading achievement among first-grade children in an urban population of mixed ethnicity and lower middle to low socioeconomic status. In the fall, children reported high levels of depressive symptoms, a risk factor for major depressive disorder. There was a linear relationship in the fall between depressive symptoms and achievement test scores. Among male children in intervention classrooms whose gain in achievement was at least the national average, depression from fall to spring was decreased, compared to those whose achievement gain was lower. Among female children both in the control and in the intervention classrooms, there was also a significant relationship between gain in achievement and the course of depression.

Depression in assisted living is common and related to physical burden

OBJECTIVE The objective of this study was to obtain a direct estimate of the prevalence of depression, its associated factors, and rates of treatment among residents of assisted living (AL) facilities in central Maryland. METHOD One hundred ninety-six AL residents were recruited from 22 (10 large and 12 small) randomly selected AL facilities in the city of Baltimore and seven Maryland counties. Chart review, staff and family history, comprehensive in-person resident evaluation, and the Cornell Scale for Depression in Dementia (CSDD) were administered by an experienced team of geriatric psychiatry clinicians. Those scoring >7 on the CSDD, a cut point repeatedly associated with poor outcomes, were considered clinically depressed. RESULTS Participants had an average age of 86 years, most were female and widowed, and 68% met consensus criteria for dementia. Twenty-four percent (47 of 196) of the sample was depressed. In bivariate analyses, depression was significantly related to medical comorbidity, need for activities of daily living (ADLs) assistance, more days spent in bed, and less participation in organized activities. After controlling for pertinent covariates in a regression model, only need for ADL assistance remained significantly associated with depression. Forty-three percent of those currently depressed were receiving antidepressants and were more likely to receive them if they lived in a large AL facility. Sixty percent of depressed residents had no regular source of psychiatric care. CONCLUSIONS In the first clinical study implemented by geriatric psychiatry professionals in AL, depression was found to be common, undertreated, and related to physical burden. AL is a rapidly growing segment of long-term care and represents an important setting in which to find and treat serious depression.

The physical environment influences neuropsychiatric symptoms and other outcomes in assisted living residents

Although the number of elderly residents living in assisted living (AL) facilities is rising, few studies have examined the AL physical environment and its impact on resident well‐being. We sought to quantify the relationship of AL physical environment with resident outcomes including neuropsychiatric symptoms (NPS), quality of life (QOL), and fall risk, and to compare the effects for demented and non‐demented residents.

History of manic and hypomanic episodes and risk of incident cardiovascular disease: 11.5 year follow-up from the Baltimore Epidemiologic Catchment Area Study

BACKGROUND While several studies have suggested that bipolar disorder may elevate risk of cardiovascular disease, few studies have examined the relationship between mania or hypomania and cardiovascular disease. The purpose of this study is to examine history of manic and hypomanic episodes as an independent risk factor for cardiovascular disease (CVD) during an 11.5 year follow-up of the Baltimore Epidemiologic Catchment Area Follow-up Study. METHODS All participants were psychiatrically assessed face-to-face based on Diagnostic Interview Schedule in 1981 and 1982 and were categorized as having either history of manic or hypomanic episode (MHE; n=58), major depressive episode only (MDE; n=71) or no mood episode (NME; n=1339). Incident cardiovascular disease (CVD; n=67) was determined by self-report of either myocardial infarction (MI) or congestive heart failure (CHF) in 1993-6. RESULTS Compared with NME subjects, the odds ratio for incident CVD among MHE subjects was 2.97 (95% confidence interval: 1.40, 6.34) after adjusting for putative risk factors. CONCLUSIONS These data suggest that a history of MHE increase the risk of incident CVD among community residents. Recognition of manic symptoms and addressing related CVD risk factors could have long term preventative implications in the development of cardiovascular disease in the community.

Effect of Dementia and Treatment of Dementia on Time to Discharge from Assisted Living Facilities: The Maryland Assisted Living Study

OBJECTIVES: To estimate the association between dementia and time to discharge from individual assisted living (AL) facilities and examine, in residents with dementia, factors associated with shorter duration of residence in individual AL facilities.

Predictors of Caregiver Unawareness and Nontreatment of Dementia Among Residents of Assisted Living Facilities: The Maryland Assisted Living Study

OBJECTIVE Assisted living (AL) is a rapidly expanding residential option for the senior population. With increased utilization, it becomes important to understand the detection and treatment of dementia in this setting, but little is known. The objective of this study was to identify and evaluate factors associated with caregiver unawareness of dementia and failure to treat dementia in AL. METHODS The setting was a cross-sectional study of a random sample of AL facilities in central Maryland (The Maryland Assisted Living Study). Geriatric psychiatrists evaluated 198 participants and assigned dementia diagnoses to 134 residents (67.7%). The extent to which dementia was recognized and treated in these facilities was estimated on the basis of caregiver interview and chart review data. Using logistic regression models, demographic, cognitive, and functional measures were evaluated as predictors of caregiver unawareness and nontreatment of dementia. RESULTS Severity of cognitive and functional impairment, number of neuropsychiatric symptoms, and male gender were all independent predictors of caregiver unawareness of dementia. Family and caregiver unawareness of dementia and female gender were predictors of failure to treat dementia. Detection and treatment were not associated with race, age, or overall medical health. CONCLUSIONS Caregivers were more likely to be unaware of dementia in residents who did not have severe cognitive impairment or obvious behavioral and functional problems. Caregiver and family unawareness were in turn associated with nontreatment. Observed gender differences in detection and treatment will require replication and further study. These observations suggest that systematic educational interventions for caregivers and families may improve detection and hence treatment in the AL setting.