Stephen Vida

Depression in Alzheimer's Disease: Receiver Operating Characteristic Analysis of the Cornell Scale for Depression in Dementia and the Hamilton Depression Scale

This study compares the performance of the Cornell Scale for Depression in Dementia (CSDD) and the Hamilton Depression Scale (HDS) in detecting Research Diagnostic Criteria (RDC) major depression in subjects with mild-to-moderate Alzheimers disease (AD). Thirty-four subjects with this diagnosis and their caregivers were interviewed. The senior author conducted a diagnostic interview to determine RDC diagnosis. An investigator, blind to diagnosis, obtained demographic information and administered the Mini Mental State Examination, Global Deterioration Scale, CSDD and HDS. For each depression scale, the correlation with the RDC diagnosis of major depression was calculated, as were the sensitivity and specificity at various cutoff scores. Nonparametric receiver operating characteristic analysis was used to compare the performance of the two scales. The area under the receiver operating characteristic curve was .91 for the CSDD and .87 for the HDS. This differed from chance to a highly significant degree for both the CSDD and the HDS but the difference between the two scales was not statistically significant. Although the precision of the present study is limited by the small sample size, a cutpoint of 7 provided reasonable performance for both the CSDD and the HDS, yielding a sensitivity of .90 for both scales and a specificity of .75 for the CSDD and 0.63 for the HDS. Although the CSDD and the HDS are rating scales rather than diagnostic instruments, receiver operating characteristic analysis indicates that both demonstrate statistically significant discriminating ability for RDC major depression in mild to moderate, probable AD. Our data suggest that for most clinical purposes, a cutpoint of 7 may be suitable for the detection of RDC major depression in mild-to-moderate probable AD.

Review of outcome measurement instruments in Alzheimer's disease drug trials: psychometric properties of behavior and mood scales.

This article reviews the reliability and validity of eight scales for behavior and mood problems that were identified in a comparative analysis ofAlzheimers disease (AD) drug trials. The scales are the Brief Psychiatric Rating Scale, the Alzheimers Disease Assessment Scale-noncognitive, the Relatives Assessment of Global Symptomatology, the Consortium to Establish a Registry for Alzheimers Disease-Behavior Rating Scale for Dementia, the Dementia Behavior Disturbance scale, the Neuropsychiatric Inventory, and two scales for depressive symptoms, the Cornell Scale for Depression in Dementia and the Dementia Mood Assessment Scale. This article also examines methodological limitations in the way the published literature has assessed the psychometric properties of these scales. The aim is to help clinicians and potential trial investigators select appropriate measurement instruments with which to assess behavior and mood problems in AD and to assist AD researchers in the evaluation of the psychometric properties of such scales. (J Geriatr Psychiatry Neurol 2000; 13:181-196).

Prevalence of Depression in Alzheimer's Disease and Validity of Research Diagnostic Criteria

This study was undertaken to estimate the point-prevalence of Research Diagnostic Criteria (RDC) depressive syndromes in Alzheimers disease (AD) and to evaluate the validity of existing and potential alternative diagnostic criteria for major depression in the presence of probable AD. Twenty-six subjects with probable AD of mild to moderate severity and their caregivers were interviewed to estimate the prevalence of RDC depressive syndromes. For the evaluation of the validity of RDC for major depression, an additional 8 probable-AD subjects with suspected depression were added to the sample. Sensitivity, specificity, and correlation with diagnosis of RDC major depression were calculated for each diagnostic criterion, and existing major depressive criteria were compared to potential alternative criteria currently used for RDC minor depression. Of the subjects in our prevalence sample, 15.4% were found to have major depression; 23.1%, minor depression; and 11.5%, intermittent depression. In our validation sample, two criteria for major depression, self-reproach/guilt and thinking/concentration difficulty, were weakly associated with the final diagnosis of major depression because of poor sensitivity or specificity. In contrast, three possible alternative criteria were significantly associated with the diagnosis of major depression and showed high sensitivity and specificity. These included nonverbal manifestations of depression, irritability/complaining, and demandingness/dependency. We conclude that RDC depressive syndromes are common in probable AD of mild to moderate severity. In the presence of AD, the validity of some existing major depressive criteria may be limited in comparison to several potential alternative criteria because of relatively poor sensitivity and/or specificity.

Occupational Exposure to Silica and Lung Cancer: Pooled Analysis of Two Case-Control Studies in Montreal, Canada

Background: Respirable crystalline silica is a highly prevalent occupational exposure and a recognized lung carcinogen. Most previous studies have focused on selected high-exposure occupational groups. This study examines the relationship between occupational exposure to silica and lung cancer in an occupationally diverse male population. Methods: Two large population-based case-control studies of lung cancer were conducted in Montreal, one in 1979-1986 (857 cases, 533 population controls, 1,349 cancer controls) and the second in 1996-2001 (738 cases and 899 controls). Interviews provided descriptive lifetime job histories, smoking histories, and other information. Industrial hygienists translated job histories into histories of exposure to a host of occupational substances, including silica. Relative risk was estimated, adjusting for several potential confounders, including smoking. Results: The odds ratio for substantial exposure to silica was 1.67 (95% confidence interval, 1.21-2.31) and for any exposure was 1.31 (95% confidence interval, 1.08-1.59). Joint effects between silica and smoking were between additive and multiplicative, perhaps closer to the latter. In this population, it is estimated that approximately 3% of lung cancers were attributable to substantial silica exposure. Conclusions: The carcinogenicity of inhaled crystalline silica was observed in a population with a wide variety of exposure circumstances. Impact: The finding of carcinogenicity across a wide range of occupations complements prior studies of specific high-exposure occupations. This suggests that the burden of cancer induced by silica may be much greater than previously thought. Cancer Epidemiol Biomarkers Prev; 19(6); 1602–11. ©2010 AACR.

Prevalence and correlates of elder abuse and neglect in a geriatric psychiatry service.

Objective: To determine the prevalence and correlates of 4 types of elder abuse and neglect in a geriatric psychiatry service. Method: We conducted a cross-sectional retrospective chart review of new in- and outpatients seen by the Montreal General Hospital Division of Geriatric Psychiatry in one calendar year. Results: Abuse or neglect was suspected or confirmed in 20 (16%) of 126 patients, comprising financial abuse in 16 (13%), neglect in 7 (6%), emotional abuse in 5 (4%), physical abuse in 3 (2%), and multiple abuse in 7 (6%). On bivariate analysis, patients living with nonspouse family, friends, or other persons were significantly more likely to have suffered abuse than were those living with their spouse or in a supervised setting (OR 10.5; 95%CI, 2.3 to 47.8); widowed, divorced, or separated patients were significantly more likely to have suffered abuse than were married patients (OR 4.7; 95%CI, 1.02 to 22.0). Nonsignificant trends included female sex (OR 4.1; 95%CI, 0.89 to 18.6); alcohol abuse (OR 2.1; 95%CI, 0.71 to 6.2); behaviour problems (OR 1.9; 95%CI, 0.71 to 5.2); and chronic cognitive impairment (OR 1.4; 95%CI, 0.55 to 3.8). Although living situation with nonspouse family, friends, or others and marital status of widowed, divorced, or separated were significantly associated with abuse when examined in separate logistic regression models, both were nonsignificant when examined together, suggesting collinearity. Both were retained in the model because they probably represent different aspects of vulnerability. The final model included living situation with nonspouse family, friends, or others (OR 6.1; 95%CI, 0.75 to 49.5) and widowed, divorced, or separated marital status (OR 2.4; 95%CI, 0.21 to 26.8). Nonsignificant trends included female sex (OR 2.6; 95%CI, 0.45 to 14.4); alcohol abuse (OR 2.2; 95%CI, 0.59 to 7.9); and lowest quartile on the Global Assessment of Functioning (GAF) scale (GAF < 35; OR 2.0; 95%CI, 0.64 to 6.0). Conclusions: The practical implications of our study are that elder abuse and neglect are common among patients referred to geriatric psychiatry services, that such services should have access to multidisciplinary expertise and resources to deal with abuse, and that certain situations may signal higher risk. In our setting, the situation of living with nonspouse family, friends, or other persons in a nonsupervised setting and a history of family disruption by widowhood, divorce, or separation were significant correlates of abuse. Suggestive but nonsignificant trends of potential importance (OR > 2.0) included female sex, alcohol abuse, and lowest quartile of functional status. Study limitations include a cross-sectional retrospective chart review design, a clinically derived sample, a small sample size, and a lack of structured instruments for several variables.

Behaviour problems of the mentally retarded.

The behaviour profiles of 176 mentally retarded individuals from two reception centres and nine group homes were assessed. The correlations between behaviour and age, sex, degree of mental retardation, etiology of mental retardation and medical diagnosis were assessed using the Revised Child Behaviour Profile. The severity of behaviour disturbance did not vary with age or medical diagnosis. The moderately retarded subjects presented with more severe behaviour problems, such as aggression, than the severely mentally retarded subjects. The variable most predictive of behavioural problems was etiology of the disorder. Individuals with Downs syndrome had significantly fewer behaviour disturbances and those with autism and pervasive developmental disorder had significantly more behaviour disturbances than other subjects. A psychiatric disorder was found in 10.2% of the sample. The implications of these findings are discussed with respect to public policy.

An update on elder abuse and neglect.

Abuse and neglect of the elderly represent an important social problem in Canada. Forms of elder abuse and neglect include physical, psychological and material abuse; neglect, both intentional and unintentional; and violation of legal rights. The definitions, signs, and symptoms of elder abuse and neglect are discussed, as are estimates of incidence and prevalence, and descriptions of possible risk factors. The evolution of legislation regarding the reporting of elder abuse and neglect is reviewed, as are relevant areas of common law, the Civil Code, and the Criminal Code. This is followed by an overview of practical considerations in clinical management, and finally by recommendations for further research.

DSM-III-R and the phenomenology of childhood bereavement: a review.

The literature on the phenomenology of childhood bereavement is reviewed. Several authors, particularly in the psychoanalytic literature, have suggested or supported the concept of “absence of grief” in children, based on the postulate that children are unable to tolerate the intense affects of mourning. More recently, systematic studies of nonclinical samples of bereaved children have found “absence of grief” to be uncommon, with most children in fact showing features such as sadness, crying, irritability, and a wide variety of other affective and behavioural symptoms. There does not appear to be a coherent syndrome of childhood bereavement, although tentative associations have been found between some phenomenological features and various child-related, family-related, societal, and circumstantial factors. The level of overall psychological adjustment after parental loss is both variable and controversial. Several tentative predictors of adverse reactions have been described. The possible place of childhood bereavement in current nosology is discussed. Preliminary evidence suggests that the phenomenology of childhood bereavement differs considerably from the DSM-III-R description of “uncomplicated bereavement.” Recent evidence suggests that the DSM-III-R concept of uncomplicated bereavement needs to be expanded to include many of the affective and behavioural features of childhood bereavement, although confirmatory controlled research is required. Suggestions for improvement of research designs are made.

Canadian collaborative study of tetrahydroaminoacridine (THA) and lecithin treatment of Alzheimer's disease: effect on mood.

Several lines of evidence have implicated acetylcholine (ACh) as one of the neurotransmitters found to be decreased in Alzheimers disease (AD). Various methods of cholinergic augmentation have been attempted, with mixed results. Tetrahydroaminoacridine (THA), an acetylcholinesterase inhibitor, is currently being investigated at the McGill Centre for Studies in Aging. Preliminary uncontrolled data from a 10-week clinical trial of THA and lecithin, reported elsewhere, suggest a clinically modest but statistically significant beneficial effect on cognition, although problems exist with side effects, particularly gastrointestinal. Since the suggestion by Janowsky in 1972 that cholinergic neurotransmission may exert an inhibitory or depressant effect on mood, the evidence accumulated in the literature has been inconclusive. We undertook to assess several potential pretreatment correlates of depressive symptoms in AD and to monitor the course of these symptoms during the 10 week treatment period, using the Geriatric Depression Scale (GDS) of Brink and Yesavage. Pretreatment GDS scores were found to correlate with degree of overall disability and dementia as measured by the Rapid Disability Rating Scale (RDRS) and the Mini Mental State Examination (MMS), respectively. GDS scores over the treatment period did not change to a statistically significant degree. The meaning of these results is discussed, particularly with reference to the difficulty of diagnosis and measurement of depression in the setting of dementia.

Brain tumours and cigarette smoking: analysis of the INTERPHONE Canada case–control study

BackgroundThere is conflicting evidence regarding the associations between cigarette smoking and glioma or meningioma. Our purpose is to provide further evidence on these possible associations.MethodsWe conducted a set of case–control studies in three Canadian cities, Montreal, Ottawa and Vancouver. The study included 166 subjects with glioma, 93 subjects with meningioma, and 648 population-based controls. A lifetime history of cigarette smoking was collected and various smoking indices were computed. Multivariable logistic regression was used to estimate odds ratios (ORs) between smoking and each of the two types of brain tumours.ResultsAdjusted ORs between smoking and each type of brain tumour were not significantly elevated for all smokers combined or for smokers with over 15 pack-years ((packs / day) x years) accumulated. We tested for interactions between smoking and several sociodemographic variables; the interaction between smoking and education on glioma risk was significant, with smoking showing an elevated OR among subjects with lower education and an OR below unity among subjects with higher education.ConclusionExcept for an unexplained and possibly artefactual excess risk in one population subgroup, we found little or no evidence of an association between smoking and either glioma or meningioma.