Temporal relation between depression and cognitive impairment in old age: prospective population based study
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《英国医生杂志》
1 Section of Gerontology and Geriatrics, Department of General Internal Medicine, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, Netherlands, 2 Department of Psychiatry, Leiden University Medical Centre, Netherlands
Correspondence to: D J Vinkers d.j.vinkers@lumc.nl
Abstract
Depression and cognitive impairment are among the most important mental health problems in elderly people. Both conditions have severe consequences, including diminished quality of life, functional decline, increased use of services, and high mortality.1 Late onset depression and cognitive impairment often occur together, suggesting a close association between them.2-4 It is not known, however, whether depression leads to cognitive decline or vice versa.4 5
Clinical practice and research evidence suggest that depression precedes cognitive decline in old age.5-10 However, inferring a relationship is hampered because most studies on this topic examined only the association between depression and the subsequent development of cognitive impairment.6-14 As depression may be an early sign rather than an independent risk factor for cognitive impairment, the temporal relation between depression and cognitive impairment in old age remains unclear.
Hitherto, only one study has investigated the temporal relation between depression and cognitive impairment in people aged 65 years and older.15 The study is limited, however, by its use of the clinical diagnosis of depression and dementia as a dichotomous endpoint. We therefore followed up 500 elderly people living in the community with annual assessments of depressive symptoms and cognitive function in order to determine their temporal relation.
Participants and methods
The figure shows the annual follow up visits for the 500 participants included in our study. During 1459 person-years of follow up (mean per person, 2.9 years), 39 people (8%) refused to participate in the repeated annual measurements, most of them at the first follow up visit. Of the 334 participants without significant depressive symptoms at baseline (geriatric depression scale score 2 points), 97 (29%) died and 28 (8%) declined to participate during follow up. Of the 415 non-demented participants at baseline (mini-mental state examination score 24 points), 124 (30%) died and 32 (8%) declined to participate during follow up.
Participant flow through study
Table 1 shows the 500 participants' demographic and clinical characteristics at baseline. Of these participants, 184 (37%) were men, 303 (61%) had only a low level of education ( 6 years of schooling), 334 (67%) had no significant depressive symptoms (geriatric depression scale score 2 points), and 415 (83%) had no serious cognitive impairment (mini-mental state exam score 24 points).
Table 1 Demographic and clinical characteristics of 500 people aged 85 years living in the community. Values are numbers (percentages) unless stated otherwise
Table 2 shows the cross sectional correlation between depressive symptoms and cognitive function at baseline. Depressive symptoms were significantly correlated with lower scores for global cognitive function, attention, processing speed, and immediate and delayed recall and with higher test scores for attention (indicating reduced attention) (all P < 0.001).
Table 2 Cross sectional correlation of depressive symptoms* with various measures of cognitive function in 500 people aged 85 years living in the community
Table 3 shows the impact of cognitive function at baseline on the course of depressive symptoms in the 334 non-depressed participants at baseline (geriatric depression scale score 2 points). An accelerated annual increase of depressive symptoms during follow up was associated with impaired attention (0.08 points (95% confidence interval 0.01 to 0.16)), poorer immediate recall (0.17 points (0.09 to 0.25)), and poorer delayed recall (0.10 points (0.02 to 0.18)) at baseline. These estimates remained similar when we included participants with a geriatric depression scale score of 2 points (data not shown).
Table 3 Impact of cognitive function at baseline on depressive symptoms from age 85 to 89 years in 334 people living in the community without depressive symptoms at baseline (GDS-15 score 2 points). Impact is additional annual increase of depressive symptoms score per SD of cognitive function test score at baseline (2.65 for global cognitive function, 31.59 for attention, 7.08 for processing, 5.72 for immediate recall, and 2.74 for delayed recall)
Table 4 shows the impact of depressive symptoms at baseline on the course of cognitive function in the 415 non-demented participants at baseline (mini-mental state exam 24 points). Depressive symptoms at baseline were not associated with an accelerated cognitive decline during follow up (P > 0.05). These estimates remained similar when we included participants with a mini-mental state exam score 24 points (data not shown).
Table 4 Impact of depressive symptoms at baseline (GDS-15 score) on cognitive decline from age 85 to 89 years in 415 people living in the community without cognitive impairment at baseline (MMSE score 24 points). Impact is additional annual impact on cognitive function per SD of mean GDS-15 score at baseline (2.11)
Discussion
Macdonald AJD. Mental health in old age. BMJ 1997;315: 413-7.
Migliorelli R, Teson A, Sabe L, Petracchi M, Leiguarda R, Starkstein SE. Prevalence and correlates of dysthymia and major depression among patients with Alzheimer's disease. Am J Psychiatry 1995;152: 37-44.
Zubenko GS, Zubenko WN, McPherson S, Spoor E, Marin DB, Farlow MR, et al. A collaborative study of the emergence and clinical features of the major depressive syndrome of Alzheimer's disease. Am J Psychiatry 2003;160: 857-66.
Jorm AF. History of depression as a risk factor for dementia: an updated review. Aust N Z J Psychiatry 2001;35: 776-81.
Schweitzer I, Tuckwell V, O'Brien J, Ames D. Is late onset depression a prodrome to dementia? Int J Geriatr Psychiatry 2002;17: 997-1005.
Devanand DP, Sano M, Tang M-X, Taylor S, Gurland BJ, Wilder D, et al. Depressed mood and the incidence of Alzheimer's disease in the elderly living in the community. Arch Gen Psychiatry 1996;53: 175-82.
Yaffe K, Blackwell T, Gore R, Sands L, Reus V, Browner WS. Depressive symptoms and cognitive decline in nondemented elderly women. Arch Gen Psychiatry 1999;56: 425-30.
Paterniti S, Verider-Taillerfer M-H, Dufouil C, Alpérovitch A. Depressive symptoms and cognitive decline in elderly people. Br J Psychiatry 2002;181: 406-10.
Green RC, Cupples LA, Kurz A, Auerbach S, Go R, Sadovnick D, et al. Depression as a risk factor for Alzheimer disease. Arch Neurol 2003;60: 753-9.
Wilson RS, Mendes de Leon CF, Bennett DA, Bienias JL, Evans DA. Depressive symptoms and cognitive decline in a community population of older persons. J Neurol Neurosurg Psychiatry 2004;75: 126-9.
Dufouil C, Fuhrer R, Dartigues J-F, Alpérovitch A. Longitudinal analysis of the association between depressive symptomatology and cognitive deterioration. Am J Epidemiol 1996;144: 634-1.
Henderson AS, Korten AE, Jacomb PA, Jorm AF, Rodgers B, Jacomb P, et al. The course of depression in the elderly: a longitudinal community-based study in Australia. Psychol Med 1997;27: 119-29.
Cervilla JA, Prince M, Joels S, Mann A. Does depression predict cognitive outcome 9 to 12 years later? Evidence from a prospective study of elderly hypertensives. Psychol Med 2000;30: 1017-23.
Broday H, Luscombe G, Anstey KJ, Cramsie J, Andrews G, Peisah C. Neuropsychological performance and dementia in depressed patients after 25-year follow-up: a controlled study. Psychol Med 2003;33: 1263-75.
Chen P, Ganguli M, Mulsant BH, DeKosky ST. The temporal relationship between depressive symptoms and dementia. Arch Gen Psychiatry 1999;56: 261-6.
Bootsma-van der Wiel A, van Exel E, de Craen AJM, Gusskloo J, Lagaay AM, Knook DL, et al. A high response is not essential to prevent selection bias: results from the Leiden 85-plus study. J Clin Epidemiol 2002;55: 1119-25.
Folstein MF, Folstein SE, McHugh PR. "Mini-mental state": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12: 189-98.
Houx PJ, Shepherd J, Blauw GJ, Murphy MB, Ford I, Bollen EL, et al. Testing cognitive function in elderly populations: the PROSPER study. J Neurol Neurosurg Psychiatry 2002;73: 385-9.
Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res 1982;1: 37-49.
De Craen AJM, Heeren TJ, Gussekloo J. Accuracy of the 15-item geriatric depression scale (GDS-15) in a community sample of the oldest old. Int J Geriatr Psychiatry 2003;18: 63-6.
Vinkers DJ, Gussekloo J, Stek ML, Westendorp RGJ, van der Mast RC. The 15-item geriatric depression scale (GDS-15) detects changes in depressive symptoms after a major negative life event. The Leiden 85-plus study. Int J Geriatr Psychiatry 2004;19: 80-4.
Gueorguieva R, Krystal JH. Move over ANOVA: progress in analyzing repeated-measures data and its reflection in papers published in the Archives of General Psychiatry. Arch Gen Psychiatry 2004;61: 310-7.
Jonker C, Geerlings MI, Schmand B. Are memory complaints predictive for dementia? A review of clinical and population-based studies. Int J Geriatr Psychiatry 2000;15: 983-91.
Geerlings SW, Beekman AT, Deeg DJ, Smit JH, Schoevers RS, de Beurs E, et al. Duration and severity of depression predict mortality in older adults in the community. Psychol Med 2002;32: 609-18.(David J Vinkers, research)
Correspondence to: D J Vinkers d.j.vinkers@lumc.nl
Abstract
Depression and cognitive impairment are among the most important mental health problems in elderly people. Both conditions have severe consequences, including diminished quality of life, functional decline, increased use of services, and high mortality.1 Late onset depression and cognitive impairment often occur together, suggesting a close association between them.2-4 It is not known, however, whether depression leads to cognitive decline or vice versa.4 5
Clinical practice and research evidence suggest that depression precedes cognitive decline in old age.5-10 However, inferring a relationship is hampered because most studies on this topic examined only the association between depression and the subsequent development of cognitive impairment.6-14 As depression may be an early sign rather than an independent risk factor for cognitive impairment, the temporal relation between depression and cognitive impairment in old age remains unclear.
Hitherto, only one study has investigated the temporal relation between depression and cognitive impairment in people aged 65 years and older.15 The study is limited, however, by its use of the clinical diagnosis of depression and dementia as a dichotomous endpoint. We therefore followed up 500 elderly people living in the community with annual assessments of depressive symptoms and cognitive function in order to determine their temporal relation.
Participants and methods
The figure shows the annual follow up visits for the 500 participants included in our study. During 1459 person-years of follow up (mean per person, 2.9 years), 39 people (8%) refused to participate in the repeated annual measurements, most of them at the first follow up visit. Of the 334 participants without significant depressive symptoms at baseline (geriatric depression scale score 2 points), 97 (29%) died and 28 (8%) declined to participate during follow up. Of the 415 non-demented participants at baseline (mini-mental state examination score 24 points), 124 (30%) died and 32 (8%) declined to participate during follow up.
Participant flow through study
Table 1 shows the 500 participants' demographic and clinical characteristics at baseline. Of these participants, 184 (37%) were men, 303 (61%) had only a low level of education ( 6 years of schooling), 334 (67%) had no significant depressive symptoms (geriatric depression scale score 2 points), and 415 (83%) had no serious cognitive impairment (mini-mental state exam score 24 points).
Table 1 Demographic and clinical characteristics of 500 people aged 85 years living in the community. Values are numbers (percentages) unless stated otherwise
Table 2 shows the cross sectional correlation between depressive symptoms and cognitive function at baseline. Depressive symptoms were significantly correlated with lower scores for global cognitive function, attention, processing speed, and immediate and delayed recall and with higher test scores for attention (indicating reduced attention) (all P < 0.001).
Table 2 Cross sectional correlation of depressive symptoms* with various measures of cognitive function in 500 people aged 85 years living in the community
Table 3 shows the impact of cognitive function at baseline on the course of depressive symptoms in the 334 non-depressed participants at baseline (geriatric depression scale score 2 points). An accelerated annual increase of depressive symptoms during follow up was associated with impaired attention (0.08 points (95% confidence interval 0.01 to 0.16)), poorer immediate recall (0.17 points (0.09 to 0.25)), and poorer delayed recall (0.10 points (0.02 to 0.18)) at baseline. These estimates remained similar when we included participants with a geriatric depression scale score of 2 points (data not shown).
Table 3 Impact of cognitive function at baseline on depressive symptoms from age 85 to 89 years in 334 people living in the community without depressive symptoms at baseline (GDS-15 score 2 points). Impact is additional annual increase of depressive symptoms score per SD of cognitive function test score at baseline (2.65 for global cognitive function, 31.59 for attention, 7.08 for processing, 5.72 for immediate recall, and 2.74 for delayed recall)
Table 4 shows the impact of depressive symptoms at baseline on the course of cognitive function in the 415 non-demented participants at baseline (mini-mental state exam 24 points). Depressive symptoms at baseline were not associated with an accelerated cognitive decline during follow up (P > 0.05). These estimates remained similar when we included participants with a mini-mental state exam score 24 points (data not shown).
Table 4 Impact of depressive symptoms at baseline (GDS-15 score) on cognitive decline from age 85 to 89 years in 415 people living in the community without cognitive impairment at baseline (MMSE score 24 points). Impact is additional annual impact on cognitive function per SD of mean GDS-15 score at baseline (2.11)
Discussion
Macdonald AJD. Mental health in old age. BMJ 1997;315: 413-7.
Migliorelli R, Teson A, Sabe L, Petracchi M, Leiguarda R, Starkstein SE. Prevalence and correlates of dysthymia and major depression among patients with Alzheimer's disease. Am J Psychiatry 1995;152: 37-44.
Zubenko GS, Zubenko WN, McPherson S, Spoor E, Marin DB, Farlow MR, et al. A collaborative study of the emergence and clinical features of the major depressive syndrome of Alzheimer's disease. Am J Psychiatry 2003;160: 857-66.
Jorm AF. History of depression as a risk factor for dementia: an updated review. Aust N Z J Psychiatry 2001;35: 776-81.
Schweitzer I, Tuckwell V, O'Brien J, Ames D. Is late onset depression a prodrome to dementia? Int J Geriatr Psychiatry 2002;17: 997-1005.
Devanand DP, Sano M, Tang M-X, Taylor S, Gurland BJ, Wilder D, et al. Depressed mood and the incidence of Alzheimer's disease in the elderly living in the community. Arch Gen Psychiatry 1996;53: 175-82.
Yaffe K, Blackwell T, Gore R, Sands L, Reus V, Browner WS. Depressive symptoms and cognitive decline in nondemented elderly women. Arch Gen Psychiatry 1999;56: 425-30.
Paterniti S, Verider-Taillerfer M-H, Dufouil C, Alpérovitch A. Depressive symptoms and cognitive decline in elderly people. Br J Psychiatry 2002;181: 406-10.
Green RC, Cupples LA, Kurz A, Auerbach S, Go R, Sadovnick D, et al. Depression as a risk factor for Alzheimer disease. Arch Neurol 2003;60: 753-9.
Wilson RS, Mendes de Leon CF, Bennett DA, Bienias JL, Evans DA. Depressive symptoms and cognitive decline in a community population of older persons. J Neurol Neurosurg Psychiatry 2004;75: 126-9.
Dufouil C, Fuhrer R, Dartigues J-F, Alpérovitch A. Longitudinal analysis of the association between depressive symptomatology and cognitive deterioration. Am J Epidemiol 1996;144: 634-1.
Henderson AS, Korten AE, Jacomb PA, Jorm AF, Rodgers B, Jacomb P, et al. The course of depression in the elderly: a longitudinal community-based study in Australia. Psychol Med 1997;27: 119-29.
Cervilla JA, Prince M, Joels S, Mann A. Does depression predict cognitive outcome 9 to 12 years later? Evidence from a prospective study of elderly hypertensives. Psychol Med 2000;30: 1017-23.
Broday H, Luscombe G, Anstey KJ, Cramsie J, Andrews G, Peisah C. Neuropsychological performance and dementia in depressed patients after 25-year follow-up: a controlled study. Psychol Med 2003;33: 1263-75.
Chen P, Ganguli M, Mulsant BH, DeKosky ST. The temporal relationship between depressive symptoms and dementia. Arch Gen Psychiatry 1999;56: 261-6.
Bootsma-van der Wiel A, van Exel E, de Craen AJM, Gusskloo J, Lagaay AM, Knook DL, et al. A high response is not essential to prevent selection bias: results from the Leiden 85-plus study. J Clin Epidemiol 2002;55: 1119-25.
Folstein MF, Folstein SE, McHugh PR. "Mini-mental state": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12: 189-98.
Houx PJ, Shepherd J, Blauw GJ, Murphy MB, Ford I, Bollen EL, et al. Testing cognitive function in elderly populations: the PROSPER study. J Neurol Neurosurg Psychiatry 2002;73: 385-9.
Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res 1982;1: 37-49.
De Craen AJM, Heeren TJ, Gussekloo J. Accuracy of the 15-item geriatric depression scale (GDS-15) in a community sample of the oldest old. Int J Geriatr Psychiatry 2003;18: 63-6.
Vinkers DJ, Gussekloo J, Stek ML, Westendorp RGJ, van der Mast RC. The 15-item geriatric depression scale (GDS-15) detects changes in depressive symptoms after a major negative life event. The Leiden 85-plus study. Int J Geriatr Psychiatry 2004;19: 80-4.
Gueorguieva R, Krystal JH. Move over ANOVA: progress in analyzing repeated-measures data and its reflection in papers published in the Archives of General Psychiatry. Arch Gen Psychiatry 2004;61: 310-7.
Jonker C, Geerlings MI, Schmand B. Are memory complaints predictive for dementia? A review of clinical and population-based studies. Int J Geriatr Psychiatry 2000;15: 983-91.
Geerlings SW, Beekman AT, Deeg DJ, Smit JH, Schoevers RS, de Beurs E, et al. Duration and severity of depression predict mortality in older adults in the community. Psychol Med 2002;32: 609-18.(David J Vinkers, research)