Specificity of Symptoms of Depression in Alzheimer Disease: A Longitudinal Analysis

doi:10.1097/00019442-200509000-00009

The American Journal of Geriatric Psychiatry

Volume 13, Issue 9, September 2005, Pages 802-807

https://doi.org/10.1097/00019442-200509000-00009 Get rights and content

Objective

Authors examined the temporal stability of symptoms of major and minor depression and apathy in dementia.

Methods

A consecutive sample of 65 patients with Alzheimer disease (AD) and depression at baseline evaluation received a follow-up psychiatric assessment that included the Structured Clinical Interview for DSM-IV and the Hamilton Rating Scale for Depression an average of 17 months later.

Results

Half of the sample had no depression at follow-up, and showed a significant improvement in sadness, guilt, suicidal ideation, disruption in sleep, loss of interest, loss of energy, thoughts of death, social withdrawal, psychomotor changes, changes in appetite/weight, and symptoms of anxiety. No significant changes were found on scores of irritability or apathy.

Conclusions

The study demonstrates the specificity of depressive symptoms in AD and suggests that apathy and depression are different behavioral domains.

Section snippets

METHODS

Our initial group consisted of a consecutive series of patients with probable AD who visited the dementia clinic at a large tertiary clinic center in Buenos Aires, Argentina. For the present study, we included those with either minor or major depression at the first assessment (N=99) and with at least one follow-up evaluation (N=65).

After the methodology of the study had been fully explained, written informed consent was obtained from the patients and their caregivers. All patients were

Demographic and Clinical Findings

Sixty-five of the 99 patients (66%) with AD and either Major or Minor depression included in the study had one or more follow-up evaluations. Lack of follow-up was due to the following: 1) Died before the minimum 12-month follow-up period (N=6); 2) Severe dementia that precluded the assessment (N=9); 3) Moved to another city or could not be traced (N=8); and 4) Refused to a follow-up evaluation (N=11). There were no significant differences between patients with or without a follow-up evaluation

DISCUSSION

We examined the reversibility of symptoms of depression in AD, and there were several important findings. First, we found that all the symptoms of depression assessed by the Ham-D showed a significant improvement with time in those patients with remission of depression. Second, patients with remission of depression showed a significant improvement in symptoms of anxiety. Third, AD patients with remission of depression did not show a concomitant reduction in the severity of apathy, demonstrating

References (28)

JT Olin et al.
Provisional diagnostic criteria for depression of Alzheimer disease: rationale and background
Am J Geriatr Psychiatry
(2002)
JT Olin et al.
Provisional diagnostic criteria for depression of Alzheimer disease
Am J Geriatr Psychiatry
(2002)
MF Folstein et al.
“Mini-Mental State:” a practical method for grading the cognitive state of patients for the clinician
J Psychiatr Res
(1975)
CG Lyketsos et al.
Depression in Alzheimer's disease: overview and treatment
Biol Psychiatry
(2002)
C Ballard et al.
The prevalence, associations, and symptoms of depression amongst dementia sufferers
J Affect Disord
(1996)
HB Lee et al.
Depression in Alzheimer's disease: heterogeneity and related issues
Biol Psychiatry
(2003)
HB Bosworth et al.
Time-to-remission from geriatric depression: psychosocial and clinical factors
Am J Geriatr Psychiatry
(2002)
GS Zubenko et al.
A collaborative study of the emergence and clinical features of the major depressive syndrome of Alzheimer's disease
Am J Psychiatry
(2003)
E Chemerinski et al.
The specificity of depressive symptoms in patients with Alzheimer's disease
Am J Psychiatry
(2001)
RL Spitzer et al.
The Structured Clinical Interview for DSM-III-R (SCID), I: history, rationale, and description
Arch Gen Psychiatry
(1992)

M Hamilton

A rating scale for depression

J Neurol Neurosurg Psychiatry

(1960)

MA Hamilton

The assessment of anxiety state by rating

Br J Med Psychol

(1959)

SE Starkstein et al.

The prevalence and clinical correlates of apathy and irritability in Alzheimer's disease

Eur J Neurol

(1995)

SE Starkstein et al.

Syndromic validity of apathy in Alzheimer's disease

Am J Psychiatry

(2001)

Cited by (50)

Measures of depression in Alzheimer’s disease
2021, Alzheimer’s Disease: Understanding Biomarkers, Big Data, and Therapy
Untreated depression in dementia is associated with increased mortality, accelerated cognitive decline, earlier nursing home placement, and decreased quality of life. Thus it is important to accurately measure and treat depression in dementia. This chapter summarizes, discusses, and compares the several existing scales that measure depression in Alzheimer’s disease (AD). Accordingly, this chapter will assess the efficiency of the following scales in accurately measuring depression in AD patients: the Cornell Scale for Depression in Dementia, the Montgomery-Asberg Depression Rating Scale, The Geriatric Depression Scale, The Hospital Anxiety and Depression Scale, Hamilton Depression Rating Scale, the Dementia Mood Assessment Scale, the Nurses Observation Scale for Geriatric Patients, National Institute of Mental Health-depression in AD measure, the Cambridge Examination for Mental Disorder of the Elderly Depression Scale, the Provisional Diagnostic Criteria for Depression in Alzheimer’s Disease, the Even Briefer Assessment Scale for Depression. Further, our review shows that depression in dementia is a complex construct that involves hopelessness, feelings of guilt, feeling worthless, thoughts of self-harm, significant change in weight or appetite, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, difficulties concentrating, and recurrent thoughts of death or suicide. These vary across patients with dementia, although the most common feature is negative mood. Importantly, our review shows that (1) some of these depression scales do not correlate, suggesting that they assess different aspects of depression; (2) reports of depression in dementia vary based on depression in dementia scale used; and (3) severe memory impairment may impact the ability to assess depression in the patients using self-reports.
Why Do They Just Sit? Apathy as a Core Symptom of Alzheimer Disease
2019, American Journal of Geriatric Psychiatry
Citation Excerpt :
However, nearly half of AD patients with apathy have no concomitant depression. Growing evidence of distinct pathophysiology and differences in appropriate pharmacologic and psychosocial interventions has led to the conclusion that apathy and depression have divergent natural histories, and that apathy is a separate and distinct syndrome from depression.2,8,11,12,14,16,23,24,27 Functional disability is unsafe for patients with dementia and is anxiety-provoking and burdensome for families and caregivers.
Apathy is common in Alzheimer disease (AD) and has a far-reaching impact on patients’ clinical course and management needs. However, it is unclear if apathy is an integral component of AD or a manifestation of depression in cognitive decline. This study aims to examine interrelationships between apathy, depression, and function.
This was a cross-sectional study of well-characterized AD patients in the National Alzheimer's Coordinating Center Uniform Data Set with a Clinical Dementia Rating (CDR) between 0.5 and 2. Participants’ function was measured using the Functional Assessment Questionnaire. Apathy and depression were measured using clinician judgment and informant-reported Neuropsychiatric Inventory–Questionnaire. Dementia severity was categorized by CDR.
Sample included 7,679 participants (55.7% men) with a mean (standard deviation) age of 74.9 (9.7) years; 3,197 (41.6%) had apathy based on clinician judgment. Among those with apathy, approximately half had no depression. Presence of apathy was associated with 21%, 10%, and 3% worsening in function compared with those without apathy in CDR 0.5, 1, and 2 groups, respectively. Depression was not independently associated with functional status. Results revealed no interaction between apathy and depression.
Apathy, but not depression, was significantly associated with worse function, with the strongest effects in mild dementia. Results emphasize the need for separate assessments of apathy and depression in the evaluation and treatment of patients with dementia. Understanding their independent effects on function will help identify patients who may benefit from more targeted management strategies.
Describing Brain Activity of Persons With AD and Depressive Symptoms
2014, Archives of Psychiatric Nursing
The purpose of this retrospective pilot study was to characterize depression of AD using electrophysiological changes in the brain activity of persons with AD and depressive symptoms. Participants had a mean age of 70.12 ± 12.68. Participants manifested an increase in absolute/relative theta activity (p = .000) over entire brain when compared to normative population-based database. Electrophysiological changes did not differ by age or gender except for increased absolute theta activity in the right lateral frontal areas (t-test = − 2.31 to − 2.39, p = .04) in females. An increased theta activity suggests that depressive symptoms may be part of AD symptomatology, not a co-morbid feature.
Severity of dementia, anosognosia, and depression in relation to the quality of life of patients with alzheimer disease: Discrepancies between patients and caregivers
2014, American Journal of Geriatric Psychiatry
To investigate the factors associated with discrepancies between patient and caregiver reports of the quality of life of patients (QoLp) with Alzheimer disease.
Cross-sectional analytic study of 141 patients and their caregivers. The instruments used were the Quality of Life in AD, the Global Deterioration Scale (GDS), the Geriatric Depression Scale, and the Anosognosia Questionnaire—Dementia. Differences were analyzed according to GDS stage. A linear regression analysis was conducted using the difference between the absolute QoLp scores of patients and caregivers. A cluster analysis involving patient variables was then performed.
The discrepancy between patient and caregiver QoLp ratings increased in line with GDS stages (χ² (2) = 8.7, p = 0.013). In the regression model (F [7,133] = 16.6, p <0.001; R² = 0.477), discrepancies in QoLp reports were associated with greater anosognosia, less depression, and a better cognitive status in patients and with female gender among caregivers. The cluster analysis showed that patients with the lowest ratings of QoLp had a better cognitive status, more depression, and less anosognosia. Conversely, the highest ratings were given by patients with a poorer cognitive status, less depression, and greater anosognosia.
The factors associated with greater discrepancies between patient and caregiver ratings of QoLp were severity of dementia, anosognosia, depression, and cognitive status in patients and female gender in caregivers. In patients with advanced dementia, greater anosognosia leads to more positive ratings in QoLp and complementary observations are required.
Neurological and psychiatric aspects of emotion
2012, Handbook of Clinical Neurology
Citation Excerpt :
Finally, AD patients with sad mood and patients with primary depression had a similar profile of somatic and psychological symptoms of depression. Starkstein and coworkers (2005b) also examined the stability of depression symptoms in a 17-month longitudinal study that included 65 AD patients with depression at intake. At follow-up, half of the sample had no depression and showed a significant decline in the symptoms of sad mood, guilt, insomnia, loss of interest, loss of energy, suicidal ideation, social withdrawal, psychomotor changes, poor appetite, and anxiety.
Neurological and psychiatric aspects of emotions have been the focus of intense research for the past 30 years. Studies in both acute (e.g., stroke, traumatic brain injury (TBI)) and chronic (e.g., dementia, Parkinson's disease) neurological disorders demonstrated a high frequency of both depression and apathy. Studies in stroke and TBI reported a significant association between lesion location and depression. Both depression and apathy are significant predictors of poor recovery among patients with brain injuries, and of steeper cognitive and functional decline among patients with neurodegenerative disorders. Poor insight and judgment are frequently found among patients with brain injury or degeneration. There is increasing evidence that damage to specific brain regions, such as the ventromedial prefrontal cortex, is associated with inappropriate emotional reactions in social contexts and diminished anxiety and concern for the future. In severe cases, behavioural changes may also include poor decision-making in the social realm, deficits in goal-directed behavior, and lack of insight into these changes. Future studies will validate specific diagnostic criteria for the various cognitive, emotional, and behavioral problems reported among patients with neurological disorders, which may result in more specific and effective treatments.
Incidence and predictive factors of depressive symptoms in Alzheimer's disease: The REAL.FR study
2011, Journal of Nutrition, Health and Aging
Many patients develop psychiatric and behavioral disturbances in the course of Alzheimer's disease (AD). Among these disturbances, depressive symptoms are frequent and affect nearly 40% of patients. The natural history and course of such symptoms in AD, and in particular the predictive factors, are little known. We studied the incidence and risk factors for the development of the first depressive symptoms in AD.
Multicenter prospective study.
Three hundred twelve AD patients from the French Network on AD (REAL.FR) without depression and without antidepressant treatment at baseline were followed up and assessed every 6 months for 4 years. During follow-up, all events occurring between two visits were carefully recorded.
We used the Neuropsychiatric Inventory (NPI) for comprehensive evaluation of behavioral and psychological symptoms and depressive symptoms in particular. A multivariate analysis was performed using a backward stepwise Cox proportional hazards model.
The incidence of depressive symptoms was 17.45% person/years, 95%CI (13.88–21.02). Among non-time dependent variables, duration of disease (RR=0.51; 95%CI: 0.30–0.85, p=0.0102) and the number of comorbid conditions (RR=0.45; 95%CI: 0.24–0.83, p=0.0115) were protective factors against the development of depressive symptoms. Agitation/aggression (RR=1.96; 95%CI: 1.19–3.23, p=0.0078) and sleep disturbances (RR=2.65; 95%CI: 1.40–5.00, p=0.0026) were time-dependent variables predictive of depressive symptoms.
Better knowledge of predictive factors of mood disturbances in AD will enable clinicians to set up appropriate management of their patients. As published longitudinal studies are few, further works should be carried out to improve knowledge of the pattern and course of depression and depressive symptoms in AD.

View all citing articles on Scopus

: This study was partially supported by grants from the Raine Foundation, the Australian Rotary Health Research Fund, and the University of Western Australia.

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Regular Research ArticleSpecificity of Symptoms of Depression in Alzheimer Disease: A Longitudinal Analysis

Objective

Methods

Results

Conclusions

Section snippets

METHODS

Demographic and Clinical Findings

DISCUSSION

Am J Geriatr Psychiatry

Am J Geriatr Psychiatry

J Psychiatr Res

Biol Psychiatry

J Affect Disord

Biol Psychiatry

Am J Geriatr Psychiatry

A collaborative study of the emergence and clinical features of the major depressive syndrome of Alzheimer's disease

Am J Psychiatry

The specificity of depressive symptoms in patients with Alzheimer's disease

Am J Psychiatry

The Structured Clinical Interview for DSM-III-R (SCID), I: history, rationale, and description

Arch Gen Psychiatry

A rating scale for depression

J Neurol Neurosurg Psychiatry

The assessment of anxiety state by rating

Br J Med Psychol

The prevalence and clinical correlates of apathy and irritability in Alzheimer's disease

Eur J Neurol

Syndromic validity of apathy in Alzheimer's disease

Am J Psychiatry

Regular Research Article
Specificity of Symptoms of Depression in Alzheimer Disease: A Longitudinal Analysis