International Journal of Geriatric Psychiatry

Generalized anxiety disorder (GAD) is a prevalent psychiatric condition in older adults with deleterious effects on health and cognition. Although selective serotonin reuptake inhibitor (SSRI) medications have some efficacy as acute treatments for geriatric GAD, incomplete response is the most common outcome of monotherapy. We therefore developed a novel sequential treatment strategy, using personalized, modular cognitive‐behavioral therapy (mCBT) to augment SSRI medication.

In an open label pilot study (N = 10), subjects received a sequenced trial of 12 weeks of escitalopram followed by 16 weeks of escitalopram augmented with mCBT. We also examined the maintenance effects of mCBT over a 28‐week follow‐up period following drug discontinuation and termination of psychotherapy.

Results suggest that (1) adding mCBT to escitalopram significantly reduced anxiety symptoms and pathological worry, resulting in full remission for most patients and (2) some patients maintained response after all treatments were withdrawn.

Findings suggest that mCBT may be an effective augmentation strategy when added to SSRI medication and provide limited support for the long‐term benefit of mCBT after discontinuation of pharmacotherapy. Copyright © 2010 John Wiley & Sons, Ltd.

People with dementia often move into care homes as their needs become too complex or expensive for them to remain in their own homes. Little is known about how well their needs are met within care homes.

The aim of this study was to identify the unmet needs of people with dementia in care and the characteristics associated with high levels of needs. Two hundred and thirty‐eight people with dementia were recruited from residential care homes nationally. Needs were identified using the Camberwell Assessment of Needs for the Elderly (CANE).

Residents with dementia had a mean of 4.4 (SD 2.6) unmet and 12.1 (SD 2.6) met needs. Environmental and physical health needs were usually met. However, sensory or physical disability (including mobility problems and incontinence) needs, mental health needs, and social needs, such as company and daytime activities, were often unmet. Unmet needs were associated with psychological problems, such as anxiety and depression, but not with severity of dementia or level of dependency.

Mental health services and residential home staff need to be aware that many needs remain unmet and much can be done to improve the quality of life of the residents with dementia. Copyright © 2005 John Wiley & Sons, Ltd.

The aim of this longitudinal study was to test the hypothesis that CSF biomarkers in AD patients also may be forward‐looking measures that are associated not only with the degree and profile of cognitive impairment but also with changes in cognition over time.

Here, we assessed the association of CSF Aβ42, T‐tau and P‐tau with neuropsychological scores of disease severity, as well as the rate of disease progression, in 142 patients with Alzheimer's disease. All patients were part of a 3‐year prospective longitudinal treatment study.

A more rapid progress in MMSE score reduction was seen in AD patients with T‐tau levels higher than the upper quartile (800 ng/L) compared with Alzheimer's disease patients with lower T‐tau levels (p = 0.008). We also found that individuals with T‐tau > 800 ng/L performed worse in total scores and especially in memory and orientation when assessed with MMSE and ADAS cog than patients with T‐tau <800 ng/L. Similar results were obtained for P‐tau. No associations were seen between Aβ42 and cognitive scores or disease progression.

These findings support the hypothesis that increased levels of T‐tau reflect the intensity of the disease and are associated with a more rapid disease progress. Copyright © 2009 John Wiley & Sons, Ltd.

Most cohort studies have found depressive symptoms to be associated with increased cardiovascular mortality in the elderly, but follow‐up times have often been short and study populations small.

To describe associations between stronger symptoms of depression and the risk of death from coronary heart disease (CHD) or myocardial infarction (MI) in elderly Finnish subjects free of CHD at the baseline.

This study is a prospective population‐based epidemiological and clinical twelve‐year follow‐up study in Lieto Health Centre, Finland. The basic population consisted of 1196 elderly (64 years of age or older) persons who lived in the municipality of Lieto in southwestern Finland in 1990. The occurrence of CHD was determined on the basis of electrocardiographic (ECG) findings, Rose questionnaire and the diagnoses in medical records. The persons with CHD were excluded from the study population. Symptoms of depression at the baseline were measured with the Zung Self‐rating Depression Scale (ZSDS). Mortality was followed up for about 12 years.

The Kaplan‐Meier survival curves showed stronger symptoms of depression to be related to high risks of mortality from CHD or MI among men and women. According to the Cox model for men significant predictors for higher risk of CHD or MI mortality were stronger symptoms of depression, higher age and a large number of medications in use. When women were examined, significant predictors were stronger symptoms of depression and a large number of medications in use.

Stronger symptoms of depression are an independent risk factor for high CHD or MI mortality in aged Finnish men and women free of CHD at baseline. Copyright © 2006 John Wiley & Sons, Ltd.

Behavioural disturbances are a common and distressing aspect of Alzheimer's disease (AD). This pooled analysis evaluated the specific benefits of memantine on behavioural disturbances in patients with moderate to severe AD.

Data were pooled from six 24/28‐week, randomised, placebo‐controlled, double‐blind studies. Of the 2,311 patients included in these studies, 1,826 patients with moderate to severe AD (MMSE <20) were included in this analysis, corresponding to the extended indication for memantine in Europe. In this subgroup, 959 patients received memantine 20 mg/day and 867 received placebo. Behavioural symptoms were rated using the Neuropsychiatric Inventory (NPI) total and single‐item scores at weeks 12 and 24/28.

At weeks 12 and 24/28, ITT analysis demonstrated that memantine treatment produced statistically significant benefits over placebo treatment in NPI total score (p = 0.001 and p = 0.008), and in NPI single items: delusions (p = 0.007 week 12, p = 0.001 week 24/28), hallucinations (p = 0.037 week 12), agitation/aggression (p = 0.001 week 12, p = 0.001 week 24/28), and irritability/lability (p = 0.005 week 24/28), LOCF population. Analysis of the patients without symptoms at baseline indicated reduced emergence of agitation/aggression (p = 0.002), delusions (p = 0.047), and disinhibition (p = 0.011), at week 12, and of agitation/aggression (p = 0.002), irritability/lability (p = 0.004), and night‐time behaviour (p = 0.050) at week 24/28 in those receiving memantine. OC analyses yielded similar results.

The data suggest that memantine is effective in treating and preventing the behavioural symptoms of moderate to severe AD. Specific persistent benefits were observed on the symptoms of delusions and agitation/aggression, which are known to be associated with rapid disease progression, increased caregiver burden, early institutionalisation, and increased costs of care. Copyright © 2007 John Wiley & Sons, Ltd.

To examine the association between the risks of depression and vascular dementia (VaD) based on Taiwan's National Health Insurance Research Database.

This retrospective longitudinal matched‐cohort study used National Health Insurance Research Database data from 49,955 participants (9,991 with new onset depression, 39,964 controls). A Cox regression analysis was performed on the whole sample and the subgroup of patients with depression. We further excluded patients who developed VaD within 3 or 5 years after enrollment to evaluate depression as an independent risk factor for or a prodrome of VaD.

During the 10‐year follow‐up period, the incidence rate ratio of VaD between patients with depression and controls was 4.24 [95% confidence interval (CI) 2.90–6.21, P < 0.001]. After adjustment for covariates, the hazard ratio (HR) of VaD in patients with depression was 3.10 (95% CI 2.13–4.52, P < 0.001). In the whole sample, risk factors for VaD besides depression were aged ≥60 years (HR = 20.08), hypertension (HR = 1.70), diabetes (HR = 1.61), coronary artery disease (HR = 2.26), head injury (HR = 2.20), and cerebrovascular disease (HR = 3.02). In patients with depression, aged ≥60 years (HR = 32.16), coronary artery disease (HR = 2.82), head injury (HR = 2.06), and cerebrovascular disease (HR = 2.37) remained risk factors for VaD. After excluding those who developed VaD within 3 or 5 years, HRs remained high (3.28, 95% CI 2.03–5.31, P < 0.001; 2.12, 95% CI 1.05–4.25, P = 0.035, respectively).

Our findings suggest that depression is an independent risk factor for subsequent VaD. Older age, cerebrovascular disease, head injury, and coronary artery disease might increase the risk of VaD among patients with depression.

Late‐onset depression (LOD) has a poor prognosis which may be worsened by the presence of cerebrovascular disease. Few studies have explored prospectively the influence of vascular risk factors on longer term prognosis.

The original study involved 50 patients with LOD and 35 healthy age matched controls. Follow‐up was at three years. Baseline measures included clinical, neuroradiological and neuropsychological variables. Outcome was assessed by mortality, progression to dementia and clinical course of depressive disorder.

Sixty‐two (73%) of the original cohort agreed to be re‐interviewed. Seven participants had died (all from the depressed group) and six developed dementia, all but one from the depressed group. Vascular dementia predominated (although not significantly so) among those with dementia at follow‐up. For 28 depressed patients with complete follow‐up data (56% of the original sample), poor outcome was predicted by lower High Density Lipoprotein (HDL), raised Erythrocyte Sedimentation Rate (ESR) and a higher score on the Hachinski Index scale and one test of immediate memory. Initial response to treatment was not associated with later outcome.

Late‐onset depressive disorder is associated with a high rate of mortality and possibly dementia. Biochemical and inflammatory markers may be important in prognosis and their role should be confirmed in future studies. Copyright © 2005 John Wiley & Sons, Ltd.