Determinants of insomnia in relatively healthy elderly. A literature review

A review is presented based on the findings resulting from interview and questionnaire research concerning factors that determine insomnia in relatively healthy elderly. The investigated factors include modes of living, sleep wishes and personality aspects. During the period 1988-1997 18 published reports were found. Based on the findings it is difficult to claim that elderly persons with insomnia are characterized by inappropriate modes of living. There were, however, some (inconsistent) indications that tea consumption, smoking and lack of exercise predicted insomnia. There were also scarce indications for less realistic sleep expectations in bad than in good sleepers. More bad sleepers perceived their sleep as uncontrollable and unpredictable than than good sleepers. Bad sleepers had significantly higher scores for anxiety, neuroticism and depression than good sleepers. Anxiety as well as depression correlated positively with insomnia and negatively with sleep duration. Depression, anxiety or neuroticism often were better predictors of insomnia than health indicators such as perceived health and number of prescribed drugs. The findings suggest that insomnia in relatively healthy elderly is more tightly associated with psychological factors than with modes of living or health indicators. This has some consequences for therapy. In addition to advice concerning modes of living and sleep hygiene, one has to be alert for the possible presence of depression or anxiety. In that case depression or anxiety has to be treated, pharmacologically or nonpharmacologically.     

Toepassing van stemmingsvragenlijsten bij ouderen met alzheimerdementie (met of zonder taalstoornis) en hun informanten

Introduction

Alzheimer’s Dementia (AD) may be associated with symptoms of depression. In AD, problems of language expression or understanding will arise sooner or later. The aim of this study was to determine whether elderly persons with AD, with or without a language disorder, experience difficulties understanding and answering mood related questions. In addition to this, it was our object to test the validity of the answers of nurses as informants, on the mood of an elderly client.

Methods

53 elderly persons, living in care homes, and their nurses, took part in the study. 25 participants had been diagnosed with Alzheimer’s disease, 28 participants had no cognitive impairment. Language skills were tested using the SAN-test (Stichting Afasie Nederland) and subtests of the Aachen Aphasia Test (AAT). Mood was assessed with the Beck Depression Inventory-second edition (BDI-II-NL) and the Geriatric Depression Scale (GDS-30).

Results

There were no significant differences in scores on the mood related questionnaires between participants without cognitive impairment and participants with Alzheimer’s disease, with or without a language disorder. The correlation between self- and informant-rating was very limited. In general, nurses reported more depressive symptoms than the elderly persons did themselves. Disparities between self- and informant-ratings varied from informant scores overestimating low self-ratings of depression to informant scores underestimating high self-ratings.

Conclusion

Alzheimer’s disease, whether or not it is complicated by a language disorder, does not disturb the normal score distribution on either test (BDI or GDS). This means that elderly persons with Alzheimer’s disease are capable of adequately answering questions related to their own mood. However, considerable discrepancies were found between observer- and self-ratings of emotional wellbeing. Therefore it is important to not only take into account the information of an informant when testing for depression, but also the elderly person’s own assessment of their mood.

     

Atypical presentation of depression in the elderly: fact or fiction?

Depression in the elderly is often thought to have a different clinical presentation in many patients. This so-called atypical depression is characterised by less sadness and feelings of guilt and more somatic symptoms, impaired cognition and behavioural symptoms. Studies that compare depressive signs and symptoms in elderly and younger patients are reviewed. Published studies do not support the suggestion that major depression in the elderly often have a different clinical presentation. Vascular depression and depression in patients with severe dementia may be exceptions. Conceptual and methodological issues that play an important role are discussed.     

Depression and adipose polyunsaturated fatty acids in the survivors of the Seven Countries Study population of Crete

The purpose of the present study was to investigate the relation between adipose tissue polyunsaturated fatty acids, an index of long-term or habitual fatty acid dietary intake and depression. The sample consisted of 150 elderly males from the island of Crete. The subjects were survivors of the Greek Seven Countries Study group. The mean age was 84 years. The number of subjects with complete data on all variables studied was 63. Subjects were examined by the Preventive Medicine and Nutrition Clinic of the University of Crete. Depression was assessed through the use of the short form of the Geriatric Depression Scale (GDS-15). Depression correlated negatively with adipose tissue alpha-linolenic acid (C18:3n-3). Depressed subjects had significantly reduced (-10.5%) adipose tissue C18:3n-3 levels than non-depressed subjects. The observed negative relation between adipose tissue C18:3n-3 and depression, in the present study, appears to indicate increasing long-term dietary C18:3n-3 intakes with decreasing depression. This agrees with findings of other studies indicating an inverse relation between depression and consumption of fish and n-3 polyunsaturated fatty acids. This is the first literature report of a relation between adipose tissue C18:3n-3 and depression. Furthermore, this is the first report of a relation between adipose PUFA and depression in an elderly sample. Depression has been reported to be associated with elevated cytokines, such as, IL-1, IL-2, IL-6, INF-gamma and INF-alpha. Fish oil and omega-3 fatty acids, on the other hand, have been reported to inhibit cytokine production. The observed negative relation between adipose C18:3n-3 and depression, therefore, may stem from the inhibiting effect of C18:3n-3 or its long-chain metabolites on cytokine synthesis.     

Relationships between depression,lifestyle and quality of life in the community dwelling elderly: a comparison between gender and age groups

This study aimed to comprehensively investigate the comprehensive relationships between depression and the characteristics of lifestyle and quality of life (QOL) of healthy, community dwelling elderly, and compare them according to gender and age groups. 1302 subjects (657 males and 645 females) were used for analysis. The investigators in this study were researchers working at universities in each prefecture. Data collection was conducted in a general delivery survey and interview setting or an education class setting. The geriatric depression scale (GDS) consisting of 15 items with a dichotomous scale was used to assess depression symptoms in the elderly. In addition, 16 items selected from the four factors of economic situation, physical health, social activity, and personal status were used to assess lifestyle. Furthermore, this study investigated life satisfaction, morale, and physical function with the LSI scale, PGC morale scale and the ADL scale of the Ministry of Education, Science and Culture, respectively. According to our results, depression characteristics of the elderly differ between gender and age groups. Depression increases in the old-old elderly rather than in the young-old elderly and is highest in old-old females. The factors significantly related to depression in community dwelling elderly were the number of friends and morale. In particular, an increase in the number of friends was related to a decrease in depression. Depression in the old-old elderly was more significantly related to many lifestyle items compared with the young-old elderly, and especially in the old-old elderly, the extent of social activities related to a decrease in depression.     

Depression in Persons with Diabetes by Age and Antidiabetic Treatment: A Cross-Sectional Analysis with Data from the Hordaland Health Study

BackgroundPersons with diabetes have increased risk of depression, however, studies addressing whether the risk varies by age and type of antidiabetic treatment have yielded conflicting results. The aim of this study was to investigate if the association between diabetes and depression varied by type of antidiabetic treatment in a large community based sample of middle-aged (40–47 years) and older adults (70–72 years).MethodsData from 21845 participants in the Hordaland Health Study (HUSK) were analyzed in a cross-sectional design. Diabetes was assessed by self-report and classified as un-medicated, treated by oral antidiabetic agents or by insulin. Depression was defined as a score ≥8 on the depression subscale of the Hospital Anxiety and Depression Scale and/or self-reported use of antidepressant agents. Associations between diabetes and depression were estimated using logistic regression.ResultsPersons in their forties with diabetes had a doubled prevalence of depression (OR: 1.96 (95% C.I.: 1.35, 2.83)) compared to persons without diabetes, while a lower and non-significant association was found among persons in their seventies. Persons in their forties with orally treated diabetes had about three times higher prevalence of depression (OR: 2.92 (95% C.I.: 1.48, 5.77)) after adjustment for gender, BMI, physical activity, alcohol consumption and education, compared to non-diabetic persons in the same age-group. No association between depression and insulin or un-medicated diabetes was found.ConclusionsClinicians should be aware that persons in their forties with orally treated diabetes are at a marked increased risk of depression.     

老年肿瘤病人抑郁症状影响因素的调查与心理干预

目的:调查分析老年肿瘤病人抑郁的影响因素,寻求解决办法。方法:对本院部分住院老年肿瘤病人发放老年抑郁量表进行调查与分析。结果:老年肿瘤病人发生抑郁的几率远大于一般人群。结论:在肿瘤的治疗过程中,只关注躯体疾病是不够的,应建立良好的社会支持系统,除了医护人员外,还要充分发挥和利用家庭、朋友、社会团体等其他社会支持的作用。     

国内7省市老年人抑郁症的检出率及影响因素分析

目的:调查分析国内7省市老年人抑郁症的检出率及特点,并从老年人基本情况、躯体健康、认知功能等方面综合分析抑郁症的影响因素。方法:采用GDS-30量表分析2011-2012年在北京、上海、哈尔滨、西安、成都、长沙和重庆市及周边乡镇的9200名60岁以上老年抑郁症的发生情况,并分析影响抑郁检出率的相关因素。结果:调查老年对象的抑郁症检出率为17.2%,其中男性为15%,女性为19.6%。女性老年人在各个年龄段的抑郁症检出率均高于男性。抑郁症检出率随着年龄的增加逐渐增加。文化水平、健康自评、认知功能与抑郁症检出率密切相关。结论:抑郁症是国内7省市老年人常见的心理疾病,女性、高龄、低文化水平、健康自评差、认知功能障碍的老年人患抑郁症的几率更高。     

Zinc Deficiency Is Common in Several Psychiatric Disorders

Background

Mounting evidence suggests a link between low zinc levels and depression. There is, however, little knowledge about zinc levels in older persons with other psychiatric diagnoses. Therefore, we explore the zinc status of elderly patients suffering from a wide range of psychiatric disorders.

Methods

Clinical data and blood samples for zinc analyzes were collected from 100 psychogeriatric patients over 64 of age. Psychiatric and cognitive symptoms were assessed using the Montgomery and Aasberg Depression Rating Scale, the Cornell Scale for Depression in Dementia, the Mini-Mental State Examination, the Clockdrawing Test, clinical interviews and a review of medical records. In addition, a diagnostic interview was conducted using the Mini International Neuropsychiatric Interview instrument. The prevalence of zinc deficiency in patients with depression was compared with the prevalence in patients without depression, and the prevalence in a control group of 882 older persons sampled from a population study.

Results

There was a significant difference in zinc deficiency prevalence between the control group (14.4%) and the patient group (41.0%) (χ² = 44.81, df = 1, p<0.001). In a logistic model with relevant predictors, zinc deficiency was positively associated with gender and with serum albumin level. The prevalence of zinc deficiency in the patient group was significantly higher in patients without depression (i.e. with other diagnoses) than in patients with depression as a main diagnosis or comorbid depression (χ² = 4.36, df = 1, p = 0.037).

Conclusions

Zinc deficiency is quite common among psychogeriatric patients and appears to be even more prominent in patients suffering from other psychiatric disorders than depression.

Limitations

This study does not provide a clear answer as to whether the observed differences represent a causal relationship between zinc deficiency and psychiatric symptoms. The blood sample collection time points varied in both the control group and the patient group. No data regarding zinc supplementation were collected.     

Late-life Onset Bipolar Disorder Presenting as a Case of Pseudo-Dementia: A Case Discussion and Review of Literature

Depression and comorbid cognitive impairment in the elderly can be difficult to distinguish from dementia. Adding to the complex differential is that depression may be part of a bipolar illness rather than a unipolar mood disorder. A diligent workup and close monitoring of patients can inform appropriate treatment and can make the difference between recovery and persistence of symptoms. The present case will illustrate how a comprehensive workup utilizing extensive data gathering, laboratory workup, use of neuropsychological testing, neuroimaging, and timely treatment can lead to successful clinical outcomes that can be sustained for many years.     

Effects of depression on physical health and mortality in the elderly. Longitudinal results of the LASA research

This longitudinal study examines the physical health consequences of depression among 3107 older persons (55-85 years). Major depression was defined according to DSM-III criteria in a psychiatric interview. Minor depression was defined by a Center for Epidemiologic Studies Depression score > or = 16. Health consequences were assessed by 3-year change in self-reported functional status, 3-year change in performance on objective tests, and risk of death over 4.5 years. At baseline, 12.8% of the older persons had minor depression and 2.0% major depression. Minor depression was associated with a significantly greater decline in functional status and performance and, only in men but not in women, with an increased risk of death. Major depression also increases decline in functional status and the risk of death (irrespective of sex), but was not associated with decline in physical performance. These results show that late-life depression has strong unfavorable physical health consequences. The consequences of minor depression are comparable with those of major depression.     

Prevalence of depression in tuberculosis patients in comparison with non-tuberculosis family contacts visiting the DOTS clinic in a Nigerian tertiary care hospital and its correlation with disease pattern

Background Individuals with chronic diseases such as tuberculosis often have comorbid de-pression that requires frequent hospitalisations. This poses great challenges to the care of such patients.Objective This study aimed at determining the prevalence of depression in tuberculosis patients in comparison with non-tuberculosis controls, and its correlation with disease pattern.Method Eighty-eight patients with tuberculosis and 81 family members visiting the DOTS Centre at University College Hospital Ibadan Centre were screened for depression. Severity of depression was assessed using the Hamilton Depression Scale and was compared with severity of pulmonary tuberculosis.Results The prevalence of depression was 45.5% among patients and 13.4% among family members. Depression was more prevalent among patients that were elderly (P = 0.001), with extensive disease (P = 0.01), of long duration (P = 0.03), those with category 2 tuberculosis (P = 0.003), those from a nuclear family (P = 0.01) and patients that were unmarried (P = 0.02).Conclusion The impact of chronic diseases such as tuberculosis extends beyond physical impairment. It includes behavioural consequences, in this instance depression, for both the patient and the primary care givers. Thus, the care of patients with tuberculosis should be comprehensive and include consultative–liaison psychiatric care.     

Protocol of a randomized controlled trial of the effectiveness of physician education and activation versus two rehabilitation programs for the treatment of Whiplash-associated Disorders: The University Health Network Whiplash Intervention Trial

Background

Depression frequently occurs in the elderly. Its cause is largely unknown, but several studies point to disturbances of biological rhythmicity. In both normal aging, and depression, the functioning of the suprachiasmatic nucleus (SCN) is impaired, as evidenced by an increased prevalence of day-night rhythm perturbations, such as sleeping disorders. Moreover, the inhibitory SCN neurons on the hypothalamus-pituitary adrenocortical axis (HPA-axis) have decreased activity and HPA-activity is enhanced, when compared to non-depressed elderly. Using bright light therapy (BLT) the SCN can be stimulated. In addition, the beneficial effects of BLT on seasonal depression are well accepted. BLT is a potentially safe, nonexpensive and well accepted treatment option. But the current literature on BLT for depression is inconclusive.

Methods/Design

This study aims to show whether BLT can reduce non-seasonal major depression in elderly patients. Randomized double blind placebo controlled trial in 126 subjects of 60 years and older with a diagnosis of major depressive disorder (MDD, DSM-IV/SCID-I). Subjects are recruited through referrals of psychiatric outpatient clinics and from case finding from databases of general practitioners and old-people homes in the Amsterdam region. After inclusion subjects are randomly allocated to the active (bright blue light) vs. placebo (dim red light) condition using two Philips Bright Light Energy boxes type HF 3304 per subject, from which the light bulbs have been covered with bright blue- or dim red light- permitting filters. Patients will be stratified by use of antidepressants. Prior to treatment a one-week period without light treatment will be used. At three time points several endocrinological, psychophysiological, psychometrically, neuropsychological measures are performed: just before the start of light therapy, after completion of three weeks therapy period, and three weeks thereafter.

Discussion

If BLT reduces nonseasonal depression in elderly patients, then additional lightning may easily be implemented in the homes of patients to serve as add-on treatment to antidepressants or as a stand-alone treatment in elderly depressed patients. In addition, if our data support the role of a dysfunctional biological clock in depressed elderly subjects, such a finding may guide further development of novel chronobiological oriented treatment strategies.

Trial registration

ClinicalTrials.gov identifier: NCT00332670     

Severity of Depression,Anxious Distress and the Risk of Cardiovascular Disease in a Swedish Population-Based Cohort

Background

Depression is known to be associated with cardiovascular diseases (CVD). This population-based cohort study aimed to determine the association between depression of varying severity and risk for CVD and to study the effect of concomitant anxious distress on this association.

Methods

We utilized data from a longitudinal cohort study of mental health, work and relations among adults (20–64 years), with a total of 10,443 individuals. Depression and anxious distress were assessed using psychiatric rating scales and defined according to DSM-5. Outcomes were register-based and self-reported cardiovascular diseases.

Findings

Overall increased odds ratios of 1.5 to 2.6 were seen for the different severity levels of depression, with the highest adjusted OR for moderate depression (OR 2.1 (95% CI 1.3, 3.5). Similar odds ratios were seen for sub-groups of CVD: ischemic/hypertensive heart disease and stroke, 2.4 (95% CI 1.4, 3.9) and OR 2.1 (95%CI 1.2, 3.8) respectively. Depression with anxious distress as a specifier of severity showed OR of 2.1 (95% CI 1.5, 2.9) for CVD.

Conclusion

This study found that severity level of depression seems to be of significance for increased risk of CVD among depressed persons, although not in a dose-response manner which might be obscured due to treatment of depression. Further, we found a higher risk of CVD among depressed individuals with symptoms of anxious distress.     

Clinical Decision Making in the Dental Treatment of the Elderly1

Dental care of elderly persons is similar to that of younger persons but is modified by a variety of age-related and age-associated changes, as well as diseases and drugs. Clinical decision-making for the dental care of elderly persons is therefore more complex. The dental disease patterns in the elderly population seem to be changing and they seem to be expressed differently, which will require actual diagnosis and more complicated treatment planning. This paper evaluates the principles of problem solving and decision making in general, and applies them to dental diagnosis and treatment planning. A model of the different types of decision making in dentistry is presented, and its component parts discussed, with emphasis on the care of the elderly patient. The conclusions of this paper are that dental care for the elderly patient is becoming extremely complex, especially as more elderly patients will be dentate and more will be demanding care. Research is needed in the area of how dentists make decisions, and in methods of teaching decision-making skills. Longitudinal studies are required to evaluate the outcomes of treatment.     

多元化教育对老年2 型糖尿病合并抑郁患者的影响

目的:探讨多元化教育对老年2型糖尿病合并抑郁患者的影响。方法:根据Zung氏抑郁自评量表(SDS),入选100名老年2型糖尿病合并抑郁患者,匹配一般资料后随机分为常规组及多元化组,对常规组进行多媒体讲课,对多元化组除了多媒体讲课,还进行户外活动、有奖竞赛、个体化辅导等多形式教育,均为期3月,对比治疗前后血糖的控制及抑郁状态的改善情况。结果:治疗后2组的血糖控制及抑郁状态均有改善,但多元化组较常规组效果更好,且多元化组在治疗后抑郁严重度也有改善(P<0.05)。结论:在老年2型糖尿病合并抑郁患者中,多元化教育更有利于血糖的控制及抑郁状态的改善。     

Rumination and Loneliness Independently Predict Six-Month Later Depression Symptoms among Chinese Elderly in Nursing Homes

Background

Previous studies conducted in Western countries independently demonstrated that loneliness and rumination are remarkable risk factors of depression among the elderly in both community and nursing homes. However, knowledge on the relationship between these three constructs among the elderly in Eastern countries is scarce. The current study aims to determine the relationship between loneliness, rumination, and depression among Chinese elderly in nursing homes.

Methods

A total of 71 elderly participants with an average age of 82.49 years completed this six-month longitudinal study. Physical reports indicated that none of the participants were clinically depressed before the study. At Time 1, their loneliness and rumination were measured using UCLA-8 Loneliness Scale and Ruminative Responses Scale. Six months later, the participants completed the Center for Epidemiologic Studies Depression Scale to assess depressive symptoms (Time 2).

Results

Multiple regression analysis revealed that both loneliness and rumination at Time 1 were the predictors of depression symptoms at Time 2 among the Chinese elderly in nursing homes. However, in the mediation analysis using PROCESS, the indirect effect between loneliness at Time 1 and depression symptoms at Time 2 was insignificant.

Conclusions

Results suggest that previous loneliness and rumination thinking are predictors of future depression symptoms among the Chinese elderly in nursing homes. However, the insignificant mediation further suggests that the differences between loneliness and rumination should be explored in future studies. Findings have important implications for mental health professionals in nursing homes in China.     

Depression and Altitude: Cross-Sectional Community-Based Study Among Elderly High-Altitude Residents in the Himalayan Regions

Suicide rates are higher at high altitudes, and some hypothesize that hypoxia is the cause. There may be a significant correlation between rates of depression and altitude, but little data exist outside the United States. The purpose of the present study is to conduct a survey of depression among the elderly highlanders in Asia. We enrolled 114 persons aged 60 years or older (mean, 69.2 ± 6.7 years; women, 58.8 %) in Domkhar (altitude, 3800 m), Ladakh, India and 173 ethnic Tibetans (mean, 66.5 ± 6.1 years; women, 61.3 %) in Yushu (altitude, 3700 m), Qinghai Province, China. The two-item Patient Health Questionnaire (PHQ-2) and the geriatric depression scale were administered. A psychiatrist interviewed the subjects who had a positive score on the PHQ-2. The results of the interview with the residents conducted by the specialist showed that two cases (1.8 %) from Domkhar and four (2.3 %) from Qinghai had depression. Despite the high altitude, the probability of depression was low in elderly highlander in Ladakh and Qinghai. Our finding seems to indicate that cultural factors such as religious outlook and social/family relationship inhibit the development of depression.     

Comparison of fecal microflora of elderly persons in rural and urban areas of Japan

The Fecal microflora of 15 healthy elderly persons with a median age of 84 years in a rural area whose inhabitants tend to be long-lived (Yuzurihara-area, Uenohara, Yamanashi Prefecture) was compared with the microflora of individuals with a median age of 68 years in an urban area (Tokyo). The diet of the elderly persons in the Yuzurihara area is characterized by a high intake of dietary fiber. Total numbers of anaerobic bacteria were significantly smaller in the elderly persons in the Yuzurihara area than those in the Tokyo area. A significantly large number of bifidobacteria, but not of lecithinase-negative clostridia, was observed in the elderly persons in the Yuzurihara area. Large numbers and high incidences of bacilli and lecithinase-positive clostridia (mainly Clostridium perfringens) were found in the elderly persons in the Tokyo area. Twenty-five genera and over 81 species were isolated from the elderly persons in the Yuzurihara area, and 25 genera and over 92 species were isolated from the elderly persons in the Tokyo area. Furthermore, significantly larger numbers of Bifidobacterium adolescentis and Fusobacterium mortiferum strains were found in the Yuzurihara group, but significant reductions in the Bacteroides buccae-oris group, B. thetaiotaomicron, Bacteroides spp., C. coccoides, C. paraputrificum, and Clostridium spp. were observed in the same group. A significantly higher isolation rate of Bacillus subtilis was observed in the elderly persons in the Tokyo area. The difference in the fecal microflora between elderly persons in Yuzurihara and those in the Tokyo area might be due to a difference in the intake of dietary fiber.