Max L. Stek

Inflammation and interleukin-1 signaling network contribute to depressive symptoms but not cognitive decline in old age.

The association between inflammation and neuropsychiatric symptoms in old age is generally accepted but poorly understood. The purpose of this study was to examine whether inflammation precedes depressive symptoms and cognitive decline in old age, and to identify specific inflammatory pathways herein. We measured serum C-reactive protein (CRP) and lipopolysaccharide-induced production of Interleukin (IL)-1beta, IL-6, Tumor Necrosis Factor (TNF)-alpha, IL-1 receptor antagonist (ra), and IL-10 levels in 85-year-old participants free from neuropsychiatric symptoms at baseline (n=267). Participants were prospectively followed for depressive symptoms (Geriatric Depression Scale) and cognitive functioning (Mini Mental State Examination) from 85 to 90 years. Higher baseline CRP levels preceded accelerated increase in depressive symptoms (p<0.001). A higher production capacity of the pro-inflammatory cytokine IL-1beta preceded a greater increase of depressive symptoms (p=0.06), whereas that of its natural antagonist IL-1ra preceded a smaller increase of depressive symptoms (p=0.003). There was no relation of CRP, IL-1beta, and IL-1ra with cognitive decline. Our findings show that in old age inflammatory processes contribute to the development of depressive symptoms but not cognitive decline. A high innate IL-1ra to IL-1beta production capacity reflects a better ability to neutralize inflammation and may therefore protect against depressive symptoms.

Schizophrenia spectrum disorders in later life: prevalence and distribution of age at onset and sex in a Dutch catchment area

OBJECTIVESnThe prevalence of schizophrenia in later life is affected by both outflow of early onset patients, due to recovery and excess mortality, and inflow of patients with a later age at onset, making it likely that characteristics of older patients differ markedly from younger patients. We assessed the prevalence of schizophrenia and spectrum disorders and their distribution according to age at onset and sex in an elderly population.nnnDESIGNnCase register study.nnnSETTING AND PARTICIPANTSnAll patients age 60 years and older, in contact with the Mental Health Organization in a psychiatric catchment area in Amsterdam (the Netherlands), diagnosed with schizophrenia, schizoaffective disorder, or delusional disorder.nnnMEASUREMENTSnOne-year prevalence estimates, including rates according to age group, age at onset, and sex. In addition, we determined the effect of using different criteria for age at onset.nnnRESULTSnThe one-year prevalence of all disorders was 0.71%, subdivided in 0.55% for schizophrenia, 0.14% for schizoaffective disorder, and 0.03% for delusional disorder. The one-year prevalence of early-onset schizophrenia was 0.35%, of late-onset schizophrenia 0.14%, and of very-late-onset schizophrenia-like psychosis 0.05%. Variation of onset criterion affected the proportion of early-onset versus late-onset schizophrenia patients stronger in women than in men. Women outnumbered men markedly in the prevalence estimates for most diagnostic subgroups, including early-onset schizophrenia.nnnCONCLUSIONSnWe found the prevalence of schizophrenia among older persons to be well within the range reported for younger populations. The considerable proportion with a later age at onset and the strong female preponderance are distinguishing characteristics of older patients with clinical implications.

Efficacy and Safety of Continuation and Maintenance Electroconvulsive Therapy in Depressed Elderly Patients: A Systematic Review

BACKGROUNDnElectroconvulsive therapy (ECT) is the most efficacious treatment in severely depressed elderly patients. Relapse and recurrence of geriatric depression after recovery is an important clinical issue, which requires vigorous and safe treatment in the long term. Continuation or maintenance ECT (M-ECT) may play an important role in this respect.nnnMETHODSnIn this systematic search, we evaluate the efficacy and safety of M-ECT in preventing depressive relapse in patients age 55 or older. Computer databases were searched for relevant literature published from 1966 until August 2010 with additional references.nnnRESULTSnTwenty-two studies met the search criteria including three randomized clinical trials. M-ECT was studied in nine studies exclusively in the elderly patients.nnnCONCLUSIONSnResearch on this clinically important topic is sparse. On the basis of available literature, M-ECT is probably as effective as continuation medication in severely depressed elderly patients after a successful course of ECT and is generally well tolerated. To date, methodologically sound studies, which take into account important issues in geriatric depression like cognition, comorbidity, and clinical parameters, are lacking.

The effects of ECT on cognitive functioning in the elderly: a review

Electroconvulsive therapy (ECT) as a single course or in maintenance form (M‐ECT) is an effective treatment in depressed elderly. However, ECT may have adverse effects on cognition.

Big Five personality and depression diagnosis, severity and age of onset in older adults

BACKGROUNDnPersonality may play an important role in late-life depression. The aim of this study is to examine the association between the Big Five personality domains and the diagnosis, severity and age of onset of late-life depression.nnnMETHODSnThe NEO-Five Factor Inventory (NEO-FFI) was cross-sectionally used in 352 depressed and 125 non-depressed older adults participating in the Netherlands Study of Depression in Older Persons (NESDO). Depression diagnosis was determined by the Composite International Diagnostic Interview (CIDI). Severity of depression was assessed by the Inventory of Depressive Symptomatology (IDS). Logistic and linear regression analyses were applied. Adjustments were made for sociodemographic, cognitive, health and psychosocial variables.nnnRESULTSnBoth the presence of a depression diagnosis and severity of depression were significantly associated with higher Neuroticism (OR=1.35, 95% CI=1.28-1.43 and B=1.06, p<.001, respectively) and lower Extraversion (OR=.79, 95% CI=.75-.83; B=-.85, p<.001) and Conscientiousness (OR=.86, 95% CI=.81.-.90; B=-.86, p<.001). Earlier onset of depression was significantly associated with higher Openness (B=-.49, p=.026).nnnLIMITATIONSnDue to the cross-sectional design, no causal inferences can be drawn. Further, current depression may have influenced personality measures.nnnCONCLUSIONSnThis study confirms an association between personality and late-life depression. Remarkable is the association found between high Openness and earlier age of depression onset.

Social Functioning Among Older Community-Dwelling Patients With Schizophrenia: A Review

Social dysfunction is a hallmark of schizophrenia and a major constituent of its burden of disease. There is a need for more data on social functioning of older schizophrenic patients, because their numbers are rapidly growing and most are residing within the community. This article reviews existing evidence on social functioning in community-dwelling schizophrenic patients older than 55 years, focusing on social roles, social support, and social skills. Thirty-six publications proved fit for inclusion in the review. Studies from outside the United States were underrepresented. The available data suggest that the majority of older schizophrenic patients are well behind their healthy age-peers with respect to various aspects of social functioning. At the same time, a considerable heterogeneity among patients can be found. Cognitive abilities feature as a factor of major impact on social functioning, outweighing clinical symptoms. When evaluating social functioning both objective and subjective appraisals should be taken into account, because they may highlight different aspects of social functioning. Social support, impact of gender, and specific characteristics of older-old patients figure among areas that should be given priority in future research of social functioning in late life schizophrenia.

Childhood abuse in late-life depression

BACKGROUNDnLittle is known about the role of childhood abuse in late-life depression. The aim of the study is therefore to study whether childhood abuse is associated with late-life depression according to its onset, and which clinical characteristics play a role in this association.nnnMETHODSnData were used from 378 depressed and 132 non-depressed persons, aged 60-93 years, from the Netherlands Study of Depression in Older persons (NESDO). Childhood abuse included psychological, physical and sexual abuse and emotional neglect.nnnRESULTSn53% of the depressed older adults reported childhood abuse, compared to 16% of the non-depressed older adults (p<0.001). Using logistic regression analyses adjusted for age, sex and level of education, depression was strongest associated with physical abuse (Odds Ratio ((OR) 13.71; 95% Confidence Interval (CI) 3.25-57.91) and least with sexual abuse (OR 5.35; 95% CI 2.36-12.14). Childhood abuse was associated with early-onset (OR 13.73, 95% CI 7.31-25.80), middle age-onset (OR 5.36, 95% CI 2.90-9.90) and late-onset depression (OR 4.74, 95% CI 2.51-8.95). In the late-onset group childhood abuse was associated with an increased number of chronic diseases.nnnLIMITATIONSnAge of depression onset and childhood abuse were asked retrospectively, which may have biased the results.nnnCONCLUSIONSnChildhood abuse is strongly related to late-life depression and its comorbidities, even in the case of late-onset depression. This might suggest that psychological wellbeing can be maintained throughout middle age, but may be disturbed in later life.

The center for epidemiological studies depression scale (CES‐D) is an adequate screening instrument for depressive and anxiety disorders in a very old population living in residential homes

The CES‐D is an instrument that is commonly used to screen for depression in community‐based studies of the elderly, but the characteristics of the CES‐D in a residential home population have not yet been studied. The aim of this study was to investigate the criterion validity and the predictive power of the CES‐D for both depressive and anxiety disorders in a vulnerable, very old population living in residential homes.

Subjective quality of life and its determinants in a catchment area based population of elderly schizophrenia patients

BACKGROUNDnSubjective quality of life (SQOL) is an established outcome measure in schizophrenia. In spite of the substantial proportion of elderly in the total schizophrenia population, evaluation of their SQOL and its determinants has been scarce and findings from epidemiological samples are lacking.nnnMETHODSnWe assessed SQOL in elderly Dutch patients with schizophrenia or schizoaffective disorder (n=107; mean age 68 years), treated within a psychiatric catchment area. Demographic, clinical and social variables were evaluated for their impact on SQOL.nnnRESULTSnThe mean SQOL score was 4.83, moderately surpassing the midpoint of the SQOL scale. Nearly half of all patients (47.7%) reported an overall favorable SQOL. Of the total variance in SQOL, clinical variables explained 50%, and social variables explained 16%, while demographic factors did not contribute. In multivariable analysis, less self-reported depressive symptoms, worse global neurocognition, and higher observer-based level of social functioning significantly predicted a higher SQOL, explaining 53% of the total variance.nnnCONCLUSIONnThe relatively high level of SQOL in this epidemiological sample of elderly patients is in line with what has been reported for both older and younger schizophrenia populations. Depressive symptoms are a robust predictor of SQOL in late life schizophrenia, clearly outweighing psychotic symptoms. This finding has major clinical relevance, as depression is amenable to therapeutic intervention.

Older Age Is Associated with Rapid Remission of Depression After Electroconvulsive Therapy: A Latent Class Growth Analysis

OBJECTIVESnThis study aims to empirically identify latent course trajectories of depressive symptoms during electroconvulsive therapy (ECT) within a cohort of patients suffering from a depressive disorder and to examine putative predictors of course.nnnMETHODSnUsing a prospective cohort multicenter collaborative ECT design, 120 patients fulfilling the Mini International Neuropsychiatric Interview criteria for major depressive disorder and referred for ECT were selected. Ratings of the 17-item Hamilton Rating Scale for Depression (HRSD) were obtained weekly during the course of ECT. Latent class growth analysis was used to identify trajectories of course during 6-week follow-up, based on weekly total HRSD scores. Characteristics of the identified classes were examined, and putative predictors for class membership were tested.nnnRESULTSnData-driven techniques identified distinct course trajectories during 6-week follow-up ECT treatment, consisting of rapid remission, moderate response, and nonremitting course trajectories. Remission rates were as high as 80.1% in the rapid remission class. Older age was associated with rapid remission, even after adjustment for putative confounders.nnnCONCLUSIONnOur results strongly confirm the favorable outcome of ECT among elderly depressed inpatients.