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1.  Activities and Adaptation in Late-Life Depression: A Qualitative Study 
Interviews with 27 community-dwelling older adults with depression shed light on activity choices of this population and underscore the need for occupational therapy practitioners to complete a client-centered, qualitative assessment to understand why activities are continued or stopped.
OBJECTIVE. We sought to understand activity choices of older adults when they were depressed.
METHOD. Each community-dwelling participant (n = 27) completed one semistructured interview while in recovery for at least 3 mo. but less than 7 mo. Transcripts were coded to identify relevant themes.
RESULTS. Six themes emerged that explained activities participants continued while depressed, and four themes described activities they stopped.
CONCLUSION. Older adults maintained many instrumental activities of daily living while depressed, and some actively adapted activities so they could continue them. Some intentionally stopped activities to direct limited energy to their highest priority activities. To guide effective intervention, it is critical for occupational therapy practitioners to complete a client-centered qualitative assessment to understand what and, most important, why activities are continued or stopped. Each theme for activities continued and activities stopped lends itself to intervention strategies.
doi:10.5014/ajot.2014.011130
PMCID: PMC4153555  PMID: 25184470
activities of daily living; adaptation, psychological; choice behavior; depressive disorder; motivation; qualitative research
2.  Late-life depression and risk of vascular dementia and Alzheimer’s disease: systematic review and meta-analysis of community-based cohort studies 
The British Journal of Psychiatry  2013;202(5):329-335.
Background
Late-life depression may increase the risk of incident dementia, in particular of Alzheimer’s disease and vascular dementia.
Aims
To conduct a systematic review and meta-analysis to evaluate the risk of incident all-cause dementia, Alzheimer’s disease and vascular dementia in individuals with late-life depression in population-based prospective studies.
Method
A total of 23 studies were included in the meta-analysis. We used the generic inverse variance method with a random-effects model to calculate the pooled risk of dementia, Alzheimer’s disease and vascular dementia in older adults with late-life depression.
Results
Late-life depression was associated with a significant risk of all-cause dementia (1.85, 95% CI 1.67-2.04, P<0.001), Alzheimer’s disease (1.65, 95% CI 1.42-1.92, P<0.001) and vascular dementia (2.52, 95% CI 1.77-3.59, P<0.001). Subgroup analysis, based on five studies, showed that the risk of vascular dementia was significantly higher than for Alzheimer’s disease (P = 0.03).
Conclusions
Late-life depression is associated with an increased risk for all-cause dementia, vascular dementia and Alzheimer’s disease. The present results suggest that it will be valuable to design clinical trials to investigate the effect of late-life depression prevention on risk of dementia, in particular vascular dementia and Alzheimer’s disease.
doi:10.1192/bjp.bp.112.118307
PMCID: PMC3640214  PMID: 23637108
3.  Preventing Depression 
Jama  2012;307(10):1033-1034.
doi:10.1001/jama.2012.271
PMCID: PMC3397158  PMID: 22416097
4.  Resting state functional connectivity and treatment response in late-life depression 
Psychiatry research  2013;214(3):10.1016/j.pscychresns.2013.08.007.
Indices of functional connectivity in the default mode network (DMN) are promising neural markers of treatment response in late-life depression. We examined the differences in DMN functional connectivity between treatment-responsive and treatment-resistant depressed older adults. Forty-seven depressed older adults underwent MRI scanning pre- and post- pharmacotherapy. Forty-six never depressed older adults underwent MR scanning as comparison subjects. Treatment response was defined as achieving a Hamilton Depression Rating Scale of 10 or less post-treatment. We analyzed resting state functional connectivity using the posterior cingulate cortex as the seed region-of-interest. The resulting correlation maps were employed to investigate between-group differences. Additionally we examined the association between white matter hyperintensity burden and functional connectivity results. Comparison of pre- and post-treatment scans of depressed participants revealed greater post-treatment functional connectivity in the frontal precentral gyrus. Relative to treatment-responsive participants, treatment-resistant participants had increased functional connectivity in the left striatum. When adjusting for white matter hyperintensity burden, the observed differences lost significance for the PCC-prefrontal functional connectivity, but not for the PCC-striatum functional connectivity. The post-treatment “frontalization” of the DMN connectivity suggests a normalizing effect of antidepressant treatment. Moreover, our study confirms the central role of white matter lesions in disrupting brain functional connectivity.
doi:10.1016/j.pscychresns.2013.08.007
PMCID: PMC3865521  PMID: 24144505
Late-life depression; Default Mode Network; treatment response; MRI; white matter hyperintensity
5.  Treatment of Post Traumatic Stress Disorder Symptoms in Emotionally Distressed Individuals 
Psychiatry research  2014;220(0):370-375.
Older individuals with emotional distress and a history of psychologic trauma are at risk for post traumatic stress disorder (PTSD) and major depression. This study was an exploratory, secondary analysis of data from the study “Prevention of Depression in Older African Americans”. It examined whether Problem Solving Therapy - Primary Care (PST-PC) would lead to improvement in PTSD symptoms in patients with subsyndromal depression and a history of psychologic trauma. The control condition was dietary education (DIET). Participants (n = 60) were age 50 or older with scores on the Center for Epidemiologic Studies -Depression scale of 11 or greater and history of psychologic trauma. Exclusions stipulated no major depression and substance dependence within a year. Participants were randomized to 6–8 sessions of either PST-PC or DIET and followed 2 years with booster sessions every 6 months; 29 participants were in the PST-PC group and 31 were in the DIET group. Mixed effects models showed that improvement of PTSD Check List scores was significantly greater in the DIET group over two years than in the PST-PC group (based on a group*time interaction). We observed no intervention*time interactions in Beck Depression Inventory or Brief Symptom Inventory-Anxiety subscale scores.
doi:10.1016/j.psychres.2014.06.043
PMCID: PMC4253016  PMID: 25107318
Post Traumatic Stress Disorder; Dietary Education; Problem Solving Therapy
6.  Predictors of Adequate Depression Treatment among Medicaid-Enrolled Adults 
Health Services Research  2010;45(1):302-315.
Objective
To determine whether Medicaid-enrolled depressed adults receive adequate treatment for depression and to identify the characteristics of those receiving inadequate treatment.
Data Source
Claims data from a Medicaid-enrolled population in a large mid-Atlantic state between July 2006 and January 2008.
Study Design
We examined rates and predictors of minimally adequate psychotherapy and pharmacotherapy among adults with a new depression treatment episode during the study period (N=1,098).
Principal Findings
Many depressed adults received either minimally adequate psychotherapy or pharmacotherapy. Black individuals and individuals who began their depression treatment episode with an inpatient psychiatric stay for depression were markedly less likely to receive minimally adequate psychotherapy and more likely to receive inadequate treatment.
Conclusions
Racial minorities and individuals discharged from inpatient treatment for depression are at risk for receiving inadequate depression treatment.
doi:10.1111/j.1475-6773.2009.01060.x
PMCID: PMC2813450  PMID: 19878343
Depression; quality of care; Medicaid
7.  Late-life Mental Health Education for Workforce Development: Brain vs. Heart? 
Purpose
There is a shortage of mental health professionals to care for a growing geriatric population. Though not mutually exclusive, clinical and didactic educational experiences promote cognition, while affective knowledge (attitude) is promoted through non-clinical exposure to seniors. This study evaluates the relative impact of cognition and attitude on career interests among healthcare students.
Methods
We developed thirteen interactive, video-documentary “lessons” on late-life mental health presenting didactic material along with stories of actual patients and families. Four of these lessons were viewed at one week intervals by forty-two students from medical school and graduate programs of social work, psychology, and nursing. Knowledge, attitudes, and inclinations towards working with seniors were assessed.
Results
Both cognition and attitudes towards seniors improved. Linear regression shows change in attitude, not cognition, predicts interest in working with seniors.
Conclusion
Educational experiences that promote affective learning may enhance interest in geriatric careers among healthcare students.
doi:10.1016/j.jagp.2013.01.031
PMCID: PMC3594556  PMID: 23567380
Geriatric Education; Workforce development; Late-life mental health education
8.  Maintenance Treatment of Depression in Old Age: A Randomized, Double-blind, Placebo-Controlled Evaluation of the Efficacy and Safety of Donepezil Combined with Antidepressant Pharmacotherapy 
Archives of general psychiatry  2011;68(1):51-60.
Context
Cognitive impairment in late-life depression is a core feature of the illness.
Objective
to test whether donepezil + antidepressant is superior to placebo + antidepressant in (1) improving cognitive performance and instrumental activities of daily living and (2) reducing recurrences of depression over two years of maintenance treatment.
Design
Randomized, double-blind, placebo controlled maintenance trial.
Setting
university clinic
Main Outcome Measures
global neuropsychological performance, cognitive instrumental ADL, and recurrent depression.
Results
Donepezil + antidepressant temporarily improved global cognition (treatment by time interaction F = 3.78, df = 2, 126, p = .03), but effect sizes were small (Cohen’s d = 0.27: group difference at 1 year). A marginal benefit to cognitive instrumental ADL was also observed (treatment by time interaction; F = 2.94; df = 2, 137, p = 0.06). The donepezil group was more likely to experience recurrent major depression: 35% [95% CI: 24%, 46%] versus 19% [95% CI: 9%, 29%] (log rank chi squared = 3.97, p = .05); hazard ratio = 2.09 [95% CI: 1.00, 4.41]. Post-hoc subgroup analyses showed that, of 57 participants with mild cognitive impairment, 3/30 on donepezil (10%; 95% CI: 0, 21%) and 9/27 on placebo (33%; 95% CI: 16%, 51%) converted to dementia over two years (Fisher exact p = 0.05). The MCI subgroup had a 44 percent recurrence rate of major depression on donepezil verses 12% on placebo (LR=4.91, p=.03). The subgroup with normal cognition (n = 73) showed no benefit on donepezil or increase in recurrence of major depression.
Conclusion
Whether ChEI should be used as augmentation in the maintenance treatment of late-life depression depends upon a careful weighing of risks and benefits in those with MCI. In cognitively intact patients, donepezil appears to have no clear benefit for preventing progression to MCI/dementia or recurrence of depression.
doi:10.1001/archgenpsychiatry.2010.184
PMCID: PMC3076045  PMID: 21199965
9.  A comparison of the frequencies of risk factors for depression in older black and white participants in a study of indicated prevention 
International psychogeriatrics / IPA  2010;22(8):1240-1247.
Background
To compare the frequencies of risk factors, we describe risks for depression as a function of race among consecutively admitted participants in a randomized clinical trial of indicated depression prevention in later life.
Methods
Seventy-two black and 143 white participants were screened for risk factors for depression.
Results
Black participants were more likely to have fewer years of education and lower household income. They were more likely to be obese, live alone, experience functional disability, have a history of alcohol and drug abuse, and have lower scores on the Mini-mental State Examination and the Executive Interview (EXIT). White participants were not found to have greater prevalence or higher mean score on any risk factor. On average, black participants experienced approximately one more risk factor than white participants (t(213) = 3.32, p = 0.0011).
Conclusions
In our sample, black participants had higher frequencies of eight risk factors for depression and a greater mean number of risk factors compared to white participants.
doi:10.1017/S1041610210001523
PMCID: PMC3040637  PMID: 20843391
indicated prevention; depression; subsyndromal; minority; risk factors
10.  The Link Between Excessive Quantity of Sleep and Deteriorated Quality of Wakefulness – Implications for the DSM-5 
Annals of neurology  2013;73(6):785-794.
Objectives
Using population-based data, we document the comorbidities (medical, neurologic and psychiatric) and consequences for daily functioning of excessive quantity of sleep (EQS), defined as a main sleep period or 24-hour sleep duration ≥9 hours accompanied by complaints of impaired functioning or distress due to excessive sleep, and its links to excessive sleepiness.
Methods
A cross-sectional telephone study using a representative sample of 19,136 non-institutionalized individuals living in the United States, aged ≥18 (participation rate: 83.2%). The Sleep-EVAL expert system administered questions on life and sleeping habits; health; and sleep, mental and organic disorders (DSM-IV-TR, ICSD-II, ICD-10).
Results
Sleeping at least 9 hours per 24-hour period was reported by 8.4% (95% confidence intervals: 8.0%-8.8%) of participants; EQS (prolonged sleep episode with distress/impairment) was observed in 1.6% (1.4% to 1.8%) of the sample. The likelihood of EQS was 3-12 times higher among individuals with a mood disorder. EQS individuals were 2-4 times more likely to report poor quality of life than non-EQS individuals as well as interference with socio-professional activities and relationships. Although between 33% and 66% of individuals with prolonged sleep perceived it as a major problem, only 6.3% to 27.5% of them reported having sought medical attention.
Interpretation
Excessive Quantity of Sleep is widespread in the general population, co-occurring with a broad spectrum of sleep, medical, neurologic and psychiatric disorders. Therefore, physicians must recognize EQS as a mixed clinical entity indicating careful assessment and specific treatment planning.
doi:10.1002/ana.23818
PMCID: PMC4142503  PMID: 23846792
11.  Treating Depression to Remission in Older Adults: A Controlled Evaluation of Combined Escitalopram with Interpersonal Psychotherapy versus Escitalopram with Depression Care Management 
Objective
More than half of older adults respond only partially to first-line antidepressant pharmacotherapy. Our objective was to test the hypothesis that a depression-specific psychotherapy, Interpersonal Psychotherapy—IPT, when used adjunctively with escitalopram, would lead to a higher rate of remission and faster resolution of symptoms in partial responders than escitalopram with depression care management (DCM).
Method
We conducted a 16-week randomized clinical trial of IPT and DCM in partial responders to escitalopram, enrolling 124 outpatients aged 60 and older. The primary outcome, remission, was defined as three consecutive weekly scores of ≤7 on the Hamilton Rating Scale for Depression (17-item). We conducted Cox regression analyses of time to remission and logistic modeling for rates of remission. We tested group differences in Hamilton depression ratings over time via mixed-effects modeling.
Results
Remission rates for escitalopram with IPT and with DCM were similar in intention-to-treat (IPT versus DCM: 58 [95% CI: 46, 71] versus 45% [33,58]; p = 0.14) and completer analyses (IPT versus DCM: 58% [95% CI: 44,72] versus 43% [30, 57]; p = 0.20). Rapidity of symptom improvement did not differ in the two treatments.
Conclusion
No added advantage of IPT over DCM was shown. Depression care management is a clinically useful strategy to achieve full remission in about 50% of partial responders.
doi:10.1002/gps.2443
PMCID: PMC3004217  PMID: 20957693
depression; late life; escitalopram; depression care management; interpersonal psychotherapy; partial response
12.  Prevention of Depressive Disorders: A Brave New World 
Depression and anxiety  2009;26(12):1062-1065.
doi:10.1002/da.20644
PMCID: PMC2991119  PMID: 19957277
13.  Impaired executive function in contemplated and attempted suicide in late life 
Objective
Executive deficits may play an important role in late-life suicide. Yet, current evidence in this area is inconclusive and does not indicate whether these deficits are broadly associated with suicidal ideation or specific to suicidal behavior. This study examined global cognition and specifically executive function impairments as correlates of suicidal ideation and suicidal behavior in depressed older adults, with the goal of extending an earlier preliminary study.
Design
Case-control study.
Setting
University-affiliated psychiatric hospital.
Participants
All were aged 60+: 83 depressed suicide attempters, 43 depressed individuals having suicidal ideation with a specific plan, 54 non-suicidal depressed participants, and 48 older adults with no history of psychiatric disorders.
Measurements
Global cognitive function - Dementia Rating Scale (DRS), Executive function - Executive Interview (EXIT).
Results
Both suicide attempters and suicide ideators performed worse than the two comparison groups on the EXIT, with no difference between suicide attempters and suicide ideators. On the DRS total score, as well as on Memory and Attention subscales, suicide attempters and ideators and non-suicidal depressed subjects performed similarly and were impaired relative to with non-psychiatric control subjects. Controlling for education, substance use disorders, and medication exposure did not affect group differences in performance on either the EXIT or DRS.
Conclusions
Executive deficits, captured with a brief instrument, are associated broadly with suicidal ideation in older depressed adults but do not appear to directly facilitate suicidal behavior. Our data are consistent with the idea that different vulnerabilities may operate at different stages in the suicidal process.
doi:10.1097/JGP.0b013e318265752f
PMCID: PMC3516623  PMID: 23567385
suicide; cognitive; executive function; depression; aged
14.  Response to Antidepressant Medications in Late Life Depression, Across the Spectrum of Cognitive Functioning 
The Journal of clinical psychiatry  2014;75(2):e100-e107.
Objective
Depression in later life frequently coexists with cognitive impairment. To inform clinical management of these co-occurring conditions, we examined the hypotheses that, relative to cognitively normal elders meeting DSM-IV criteria for major depression, those with cognitive impairment would require greater intensity of pharmacotherapy to reach criteria for response, and take longer to respond.
Method
Using data from the recent Maintenance Therapies in Late Life Depression (MTLD-3) study, we conducted a series of secondary analyses examining the implications of cognitive impairment for short-term, open-trial pharmacotherapy of late-life depression (major depression in individuals aged 65 years and older). This short-term treatment trial consisted of three steps: initial treatment with an SSRI, subsequent switch to an SNRI if patient did not meet criteria for response, and addition of an atypical antipsychotic (AAP) for non-response to SNRI monotherapy. The first subject entered the MTLD-3 protocol in April 2004, and the last subject exited the protocol in September 2009. We examined data for participants who completed the acute phase of MTLD-3 as responders and received a consensus cognitive diagnosis (N=153) from the University of Pittsburgh Alzheimer’s Disease Research Center, based on National Alzheimer Coordinating Center Uniformed Data Set criteria. We divided participants into three groups, based on cognitive diagnosis: normal cognitive function (N=74), Mild Cognitive Impairment (N=60), and dementia (N=19). For each group, we calculated the proportion of participants who required first (SSRI), second (SNRI), or third-step (add-on AAP) treatment to meet criteria for clinical response (HRSD-17 score ≤ 10 for three consecutive weeks). We compared time to response across groups, and examined patterns of response by inspection of weekly HRSD-17 scores. Finally, we examined correlates of non-response.
Results
The three groups did not differ significantly with respect to time to response (p=0.84), trajectories to response, or intensity of antidepressant pharmacotherapy (p=0.68). Non-response was more strongly correlated with longer index MDE duration (p=0.0015), presence of recurrent depression (p=0.002), and younger current age (p=0.047), rather than with cognitive status (p=0.61).
Conclusion
Cognitive status does not appear to impact short-term pharmacotherapy response variability in individuals whose depression responds to treatment with open-trial antidepressant pharmacotherapy delivered in a supportive, university-based medication clinic.
doi:10.4088/JCP.13m08442
PMCID: PMC4060895  PMID: 24602256
late life depression; mild cognitive impairment; dementia; treatment response variability
15.  Can performance of daily activities discriminate between older adults with normal cognitive function and those with Mild Cognitive Impairment? 
OBJECTIVES
Our primary aim was to examine whether preclinical disability in performance of cognitively-focused instrumental activities of daily living (C-IADL) tasks can discriminate between older adults with normal cognitive function and those with Mild Cognitive Impairment (MCI). The secondary purpose was to determine the two tasks with the strongest psychometric properties and assess their discriminative ability. Our goal was to generate diagnosis-relevant information about cognitive changes associated with MCI and DSM-5 Mild Neurocognitive Disorder.
DESIGN
Secondary analyses of cross-sectional data from a cohort of individuals diagnosed with normal cognitive function or MCI.
SETTING
Private home locations in Pittsburgh, PA.
PARTICIPANTS
Older adults with remitted major depression (N=157).
MEASUREMENTS
Diagnosis of cognitive status was made by the Alzheimer’s Disease Research Center at the University of Pittsburgh. Performance of 8 C-IADL was measured using the criterion-referenced, observation-based Performance Assessment of Self-Care Skills (PASS).
RESULTS
A total of 96 older adults with normal cognitive function (mean age=72.5, SD=5.9) and 61 older adults with MCI (mean age=75.5, SD=6.3) participated. The 8 C-IADL demonstrated 81% accuracy in discriminating cognitive status (area under curve 0.81, p<0.001). Two tasks (shopping and checkbook balancing) were the most discriminating (area under curve 0.80, p<0.001); they demonstrated similar ability, as the 8 C-IADL, to discriminate cognitive status. Assessing performance on these two C-IADL takes 10–15 minutes.
CONCLUSION
This is the first demonstration of the discriminative ability of preclinical disability in distinguishing MCI from cognitively normal older adults. These findings highlight potential tasks, when measured with the observation-based PASS, which demonstrate increased effort for individuals with MCI. These tasks may be considered when attempting to diagnose MCI or Mild Neurocognitive Disorder in clinical practice and research.
doi:10.1111/jgs.12878
PMCID: PMC4107156  PMID: 24890517
Cognitive Function; Mild Cognitive Impairment; Mild Neurocognitive Disorder; Activities of Daily Living; Instrumental Activities of Daily Living
16.  Getting to Remission: Use of Aripiprazole for Incomplete Response in Late-Life Depression 
Objective
To determine the feasibility and safety of aripiprazole augmentation for incomplete response to sequential SSRI and SNRI pharmacotherapy in late-life depression.
Method
This study was a 12-week open-label pilot study of 24 patients aged 65 and above (mean age 73.9) diagnosed with MDD who responded partially (Hamilton Rating Scale for Depression [HRSD, 17-item] score of 11–15) or not at all (HRSD >15) to a 16-week trial of escitalopram, followed by either duloxetine (up to 120 mg/d for 12 weeks) or venlafaxine (up to 225 mg/d for 12 weeks). Subjects received 2.5–15 mg/day of adjunctive aripiprazole (average dose 9.0 mg) for 12 weeks. The criterion for remission during treatment with aripiprazole was HRSD ≤ 10 for 2 consecutive weeks.
Results
Of 24 subjects in the intent to treat study group, 19 completed 12 weeks of augmentation with aripiprazole, 12/24 (50%) met criteria for remission, and 2/24 discontinued due to side effects (sedation, akathisia). The mean HRSD score decreased significantly by 6.4 (5.8) points (paired t-test for means, p<0.01, df=16). There were no relapses among the 12 subjects who participated in continuation treatment over a median period of 27.6 weeks.
Conclusions
In older adults with MDD with incomplete response to SSRI and SNRI pharmacotherapy, aripiprazole was well tolerated, and symptoms of depression improved significantly during treatment with aripiprazole. A randomized double-blind, placebo-controlled trial of adjunctive aripiprazole for incomplete response in late-life depression is warranted, to further evaluate benefit and risk.
PMCID: PMC2886714  PMID: 19210951
aripiprazole; incomplete response; late-life depression
17.  Communication Profiles of Psychiatric Residents and Attending Physicians in Medication-Management Appointments: A Quantitative Pilot Study 
Objective
The authors quantitatively examined differences in psychiatric residents’ and attending physicians’ communication profiles and voice tones.
Methods
Audiotaped recordings of 49 resident–patient and 35 attending–patient medication-management appointments at four ambulatory sites were analyzed with the Roter Interaction Analysis System (RIAS). Nonparametric tests were used to compare differences in proportions of speech devoted to relationship-building, activating, and partnering in decision-making processes, and data-gathering/counseling/patient education. Differences in affect expressed by psychiatrists’ voice tones were also examined.
Results
Residents’ visits were twice as long as Attendings’ visits (28.2 versus 14.1 minutes), and residents devoted a significantly greater proportion of their talk to relationship-building (23% versus 20%) and activating/partnering (36% versus 28%) aspects of communication, whereas Attendings devoted a greater proportion to biomedically-related data-gathering/counseling/ patient education (31% versus 20%). Analysis of voice tones revealed that residents were perceived as sounding significantly friendlier and more sympathetic, versus Attendings, who were rated as sounding more dominant and rushed.
Conclusion
These findings show distinct communication profiles and voice-tone differences. Future psychiatric communication research should address the influence of appointment length, psychiatrist/patient characteristics, and other potential confounders on psychiatrist–patient communication.
doi:10.1176/appi.ap.10120030
PMCID: PMC4091875  PMID: 22532197
18.  Coaching in Healthy Dietary Practices in At-Risk Older Adults: A Case of Indicated Depression Prevention 
The American journal of psychiatry  2014;171(5):499-505.
Prevention of major depressive disorder is important because current treatments are only partially adequate in reducing symptom burden and promoting health-related quality of life. Lifestyle interventions may be a desirable prevention strategy for reasons of patient preference, particularly among older patients from minority groups. Using evidence from a randomized depression prevention trial for older adults, the authors found that coaching in healthy dietary practices was potentially effective in protecting at-risk older adults from developing incident episodes of major depression. The authors describe the dietary coaching program (highlighted in a case example) as well as the feasibility and potential efficacy of the program within the context of evidence-based interventions for preventing episodes of major depression and mitigating symptoms of depression. Older adults receiving dietary coaching experienced a low incidence of major depressive episodes and exhibited a 40%–50% decrease in depressive symptoms, as well as enhanced well-being, during the initial 6-week intervention; these gains were sustained over 2 years. The authors also describe why lifestyle interventions like coaching in healthy dietary practices may hold promise as effective, practical, nonstigmatizing interventions for preventing episodes of major depressive disorder in older adults with sub-syndromal depressive symptoms.
doi:10.1176/appi.ajp.2013.13101373
PMCID: PMC4083759  PMID: 24788282
19.  Protecting Sleep, Promoting Health in Later Life: A Randomized Clinical Trial 
Psychosomatic medicine  2009;72(2):178-186.
Objectives
To determine in healthy people aged ≥75 years 1) if restricting time in bed and education in health sleep practices are superior to an attention-only control condition (i.e., education in healthy dietary practices) for maintaining or enhancing sleep continuity and depth over 2.5 years; and 2) if maintenance or enhancement of sleep continuity and depth promotes the maintenance or enhancement of health-related quality of life.
Methods
Single-blind, randomized, clinical trial in a university-based sleep center, enrolling 64 adults (n = 30 women, 34 men; mean age = 79 years) without sleep/wake complaints (e.g., insomnia or daytime sleepiness), followed by randomized assignment to either: 1) restriction of time in bed by delaying bedtime 30 minutes nightly for 18 months, together with education in healthy sleep practices (SLEEP); or 2) attention-only control condition with education in health dietary practices (NUTRITION).
Results
SLEEP did not enhance sleep continuity or depth; however, compared with NUTRITION, SLEEP was associated with decreased time spent asleep (about 30 minutes nightly over 18 months). Contrary to hypothesis, participants in SLEEP reported a decrement in physical health-related quality of life and an increase in medical burden (cardiovascular illness), relative to NUTRITION. Neither markers of inflammation, body mass index, or exercise explained treatment-related changes in medical burden.
Conclusions
Although we cannot exclude a positive effect of education in healthy nutrition, for healthy elderly >75 years of age without sleep complaints, reducing sleep time may be detrimental, whereas allowing more time to sleep (about 7.5 hours nightly) is associated with better maintenance of physical health-related quality of life and stability of medical illness burden over 30 months.
doi:10.1097/PSY.0b013e3181c870a5
PMCID: PMC2846078  PMID: 19995884
sleep; aging; quality of life; physical health; inflammation
20.  Serotonin-norepinephrine reuptake inhibitor therapy in late-life depression is associated with increased marker of bone resorption 
Purpose
Antidepressants have been associated with increased bone loss and fractures in older adults in observational studies, but the mechanism is unclear. We examined the effects of a serotonin-norepinephrine reuptake inhibitor, venlafaxine, on biomarkers of bone turnover in a prospective treatment study of late-life depression.
Methods
76 individuals aged 60 and older with current major depressive disorder received a 12-week course of venlafaxine XR 150-300mg daily. We measured serum C-terminal cross-linking telopeptide of type I collagen (β-CTX) and N-terminal propeptide of type I procollagen (P1NP), measures of bone resorption and formation, respectively, before and after treatment. We then analyzed the change in β-CTX and P1NP within each participant. Venlafaxine levels were measured at the end of the study. We assessed depression severity at baseline and remission status after treatment.
Results
After 12 weeks of venlafaxine, β-CTX increased significantly, whereas P1NP did not significantly change. The increase in β-CTX was significant only in participants whose depression did not remit (increase of 10% in non-remitters versus 4% in remitters). Change in β-CTX was not correlated with serum levels of venlafaxine or norvenlafaxine.
Conclusion
Our findings suggest that the primary effect of serotonergic antidepressants is to increase bone resorption. However, such an increase in bone resorption seemed to depend on whether or not participants’ depression remitted. Our results are in agreement with prior observational studies reporting increased bone loss in older adults taking serotonergic antidepressants. These negative effects on bone homeostasis could potentially contribute to increased fracture risk in older adults.
doi:10.1007/s00198-012-2170-z
PMCID: PMC4066460  PMID: 23358607
21.  Just Say Know: An Examination of Substance Use Disorders among Older Adults in Gerontological and Substance Abuse Journals 
Social work in public health  2013;28(0):377-387.
This article examines the extent to which studies of alcohol abuse, illicit drug use, and prescription drug abuse among older adults appear in the leading gerontological and substance abuse journals. The authors reviewed articles published in the 10 social science gerontological journals and the 10 social science substance abuse journals with the highest 5-year impact factors in PubMed from 2000 to 2010. Articles were selected that presented original research on alcohol, substance, or prescription abuse with older adults aged 50 and older; and were identified through aging and substance abuse-related Medical Subject Headings and word searches of titles and abstracts (N = 634). Full text of each article was reviewed by the authors, and consensus determined inclusion in the final sample. Of the 19,953 articles published respectively in the top 10 gerontological and substance abuse journals, 181 articles met the inclusion criteria of reporting findings related to substance use disorders among older adults. Specifically, 0.9% (102 of 11,700) of articles from the top 10 gerontology journals and 1.0% (79 of 8,253) of articles from the top 10 substance abuse journals met the criteria. Most published articles addressed alcohol misuse/abuse or polysubstance abuse with few articles addressing illicit drug use or the misuse of prescription medications. Less than 1% of articles published in the 10 gerontology journals and the 10 substance abuse journals with the highest 5-year impact scores addressed substance abuse in older adults. Practitioners treating health and/or mental health problems are at a disadvantage in accurately identifying and treating these conditions in older adult populations without a proper understanding of the role of comorbid substance use disorders.
doi:10.1080/19371918.2013.774668
PMCID: PMC4047645  PMID: 23731426
Older adults; substance-related disorders; alcohol-related disorders; bibliometric analysis; prescription drug abuse; addiction
22.  Sleeping Well, Aging Well: A Descriptive and Cross-Sectional Study of Sleep in “Successful Agers” 75 and Older 
Objectives
To examine diary-based, laboratory-based, and actigraphic measures of sleep in a group of healthy older women and men (≥75 years of age) without sleep/wake complaints and to describe sleep characteristics which may be correlates of health-related quality of life in old age.
Design
Cross-sectional, descriptive study.
Setting
University-based sleep and chronobiology program.
Intervention
None.
Participants
Sixty-four older adults (30 women, 34 men; mean age 79)
Measurements
We used diary-, actigraphic-, and laboratory-based measures of sleep, health-related quality of life, mental health, social support, and coping strategies. We used two-group t-tests to compare baseline demographic and clinical measures between men and women, followed by ANOVA on selected EEG measures to examine first-night effects as evidence of physiological adaptability. Finally, we examined correlations between measure of sleep and health-related quality of life.
Results
We observed that healthy men and women aged 75 and older can experience satisfactory nocturnal sleep quality and daytime alertness, especially as reflected in self-report and diary-based measures. Polysomnography (psg) suggested the presence of a first-night effect, especially in men, consistent with continued normal adaptability in this cohort of healthy older adults. Continuity and depth of sleep in older women were superior to that of men. Diary-based measures of sleep quality (but not psg measures) correlated positively (small to moderate effect sizes) with physical and mental health-related quality of life.
Conclusions
Sleep quality and daytime alertness in late life may be more important aspects of successful aging than previously appreciated. Good sleep may be a marker of good functioning across a variety of domains in old age. Our observations suggest the need to study interventions which protect sleep quality in older adults to determine if doing so fosters continued successful aging.
doi:10.1097/JGP.0b013e3181557b69
PMCID: PMC2772651  PMID: 18070833
sleep; successful aging; aging; health-related quality of life
23.  Preventing Depression in Later Life: Translation From Concept to Experimental Design and Implementation 
Objective
The authors detail the public health need for depression prevention research and the decisions made in designing an experiment testing problem solving therapy as “indicated” preventive intervention for high-risk older adults with subsyndromal depression. Special attention is given to the recruitment of African Americans because of well-documented inequalities in mental health services and depression treatment outcomes between races.
Methods
A total of 306 subjects (half white, half African American) with scores of 16 or higher on the Center for Epidemiological Studies of Depression Scale, but with no history of major depressive disorder in the past 12 months, are being recruited and randomly assigned to either problem solving therapy-primary care or to a dietary education control condition. Time to, and rate of, incident episodes of major depressive disorder are to be modeled using survival analysis. Level of depressive symptoms will be analyzed via a mixed models approach.
Results
Twenty-two subjects have been recruited into the study, and to date eight have completed the randomly assigned intervention and postintervention assessment. Four of 22 have exited after developing major depressive episodes. None have complained about study procedures or demands. Implementation in a variety of community settings is going well.
Conclusion
The data collected to date support the feasibility of translating from epidemiology to RCT design and implementation of empirical depression prevention research in later life.
doi:10.1097/JGP.0b013e318165db95
PMCID: PMC2766668  PMID: 18515690
Depression prevention; indicated preventive intervention; elderly; African American; translation
24.  The Long-Term Effects of Conventional and Atypical Antipsychotics in Patients With Probable Alzheimer’s Disease 
The American journal of psychiatry  2013;170(9):1051-1058.
Objective
The authors sought to determine the effects of conventional and atypical antipsychotic use on time to nursing home admission and time to death in a group of outpatients with mild to moderate probable Alzheimer’s disease.
Method
The authors examined time to nursing home admission and time to death in 957 patients with the diagnosis of probable Alzheimer’s disease who had at least one follow-up evaluation (mean follow-up time, 4.3 years [SD=2.7]; range, 0.78–18.0 years) using Cox proportional hazard models adjusted for age, gender, education level, dementia severity, hypertension, diabetes mellitus, heart disease, extrapyramidal signs, depression, psychosis, aggression, agitation, and dementia medication use.
Results
A total of 241 patients (25%) were exposed to antipsychotics at some time during follow-up (conventional, N=138; atypical, N=95; both, N=8). Nursing home admission (63% compared with 23%) and death (69% compared with 34%) were more frequent in individuals taking conventional than atypical antipsychotics. In amodel that included demographic and cognitive variables, hypertension, diabetes mellitus, heart disease, incident strokes, and extrapyramidal signs, only conventional antipsychotic use was associated with time to nursing home admission. However, the association was no longer significant after adjustment for psychiatric symptoms. Psychosis was strongly associated with nursing home admission and time to death, but neither conventional nor atypical antipsychotics were associated with time to death.
Conclusions
The use of antipsychotic medications, both conventional and atypical, was not associated with either time to nursing home admission or time to death after adjustment for relevant covariates. Rather, it was the presence of psychiatric symptoms, including psychosis and agitation, that was linked to increased risk of institutionalization and death after adjustment for exposure to antipsychotics.
doi:10.1176/appi.ajp.2013.12081046
PMCID: PMC3990263  PMID: 23896958
25.  Depression in Late-Life: a Focus on Prevention 
Depression is a leading cause of disease burden, disability and distress for millions of older adults. Thus, prevention of late-life depression is a priority research area. This article addresses the science of late-life depression prevention with the following: 1) an introduction to the Institute of Medicine framework of universal, selective and indicated prevention as it pertains to late-life depression, with particular attention to successes of indicated and selective prevention in primary care; 2) a discussion of how biomarkers can be integrated into prevention research, using interferon-alpha-induced depression as a model; 3) an outline for expansion of prevention to non-specialist care delivery systems in Low and Middle Income Countries – thus, extending the reach of current successful approaches; 4) a description of a novel approach to simultaneous testing of universal, selective and indicated prevention in late-life depression, with emphasis on study design features required to achieve practical, scalable tests of health impact.
doi:10.1176/appi.focus.11.1.22
PMCID: PMC3982610  PMID: 24729758

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