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Original Article |

The Temporal Relationship Between Depressive Symptoms and Dementia:  A Community-Based Prospective Study FREE

Peijun Chen, MD, MPH; Mary Ganguli, MD, MPH; Benoit H. Mulsant, MD; Steven T. DeKosky, MD
[+] Author Affiliations

From the Department of Epidemiology, Graduate School of Public Health (Drs Chen and Ganguli); the Division of Geriatrics and Neuropsychiatry, Department of Psychiatry, School of Medicine, Western Psychiatric Institute and Clinic (Drs Ganguli, Mulsant, and DeKosky), University of Pittsburgh, Pittsburgh, Pa.


Arch Gen Psychiatry. 1999;56(3):261-266. doi:10.1001/archpsyc.56.3.261.
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Published online

Background  The temporal relationship between the appearance of depressive symptoms and the clinical onset of dementia and Alzheimer disease was evaluated in a community sample.

Methods  An original sample of 1366 subjects aged 65 years or older, selected randomly from a rural Pennsylvania community, was cognitively screened at study entry and every 2 years thereafter. A subset of 954 survivors of this cohort without dementia was screened for depressive symptoms at the second and subsequent data-collection waves. A "depression cluster" was identified by the presence of 5 or more depressive symptoms, including depressed mood, at the time of screening. Cognitively impaired subjects and a sample of unimpaired controls underwent standardized clinical evaluation to determine the presence of incident dementia (by DSM-III-R criteria) and probable or possible Alzheimer disease (by criteria of the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association) and to estimate the clinical onset of dementia symptoms.

Results  A highly increased probability of the depression cluster developing existed among subjects following the onset of dementia (15.4% [6/39]) and Alzheimer disease (17.6% [6/34]) compared with subjects without dementia (3.2% [23/712]). The odds ratios, after adjustment for age, sex, education level, and self-reported memory loss, for the development of depression were 6.5 (95% confidence interval, 2.2-19.1) in subjects with Alzheimer disease and 5.2 (95% confidence interval, 1.8-15.2) in subjects with overall dementia. Depressive symptoms did not confer a significantly increased relative risk of dementia (1.27; 95% confidence interval, 0.55-2.93) or Alzheimer disease (1.28; 95% confidence interval, 0.51-3.20).

Conclusion  Depressive symptoms appeared to be early manifestations, rather than predictors, of Alzheimer disease in this community sample.

Figures in this Article

DEPRESSION AND dementia (including Alzheimer disease [AD]) are among the most prevalent and disabling mental disorders among elders.1,2 Their frequent coexistence has stimulated speculation that complex associations exist between these 2 conditions.35

Despite the cross-sectional association between depression and dementia or AD,610 the temporal and causal nature of the relationship has yet to be determined. Some studies3,1114 have suggested that depression is a prodrome of dementia or that it co-occurs with early AD or other dementias, whereas other studies1517 did not find such relationships. Results have been inconsistent among studies examining depression as a risk factor for the development of dementia or AD. Two large prospective cohort studies6,18 found that depressive symptoms did not predict the onset of cognitive decline or dementia within a few years. By contrast, pooled data19 from 4 case-control studies showed an association between a remote history of depression and a subsequent diagnosis of AD, and 2 cohort studies showed an elevated risk of dementia developing among those with depression20 or depressed mood.21

The above-cited inconsistent results likely reflect methodological differences among studies, including study design, sample size, generalizability, measurements, diagnoses, and the selection of different time frames and end points. As Devanand et al21 suggested, a prediction of dementia by recent depression can imply that depression is either an early manifestation of dementia or a true risk factor for dementia.

We evaluated the temporal relationship between the appearance of depressive symptoms and the clinical onset of dementia or AD in a community-based prospective study. Specifically, we tested whether depressive symptoms predict the clinical onset of dementia or AD and whether the appearance of depressive symptoms follows the clinical onset of dementia or AD.

SUBJECTS

The data reported here were derived from a community-based multiwave prospective study, the Monongahela Valley Independent Elders Survey (MoVIES).2226 This survey is an ongoing project first established in 1987 as a model population-based registry for dementing disorders. At study entry (wave 1), the MoVIES cohort included 1366 subjects aged 65 years or older (97.0% white, 54.6% women, and 54.2% with at least a high school education). This cohort represented a 1:13 age-stratified sample selected randomly from the voter registration lists of 23 communities of the mid–Monongahela Valley, about 40 km south of Pittsburgh, Pa.22 The MoVIES cohort was then observed prospectively in a series of data-collection "waves" at, on average, 2-year intervals. Starting from wave 2, data on depressive symptoms were collected at each wave using a modified Center for Epidemiological Studies Depression Scale (mCES-D),23,24 described later. The data in this article were derived from completed waves 2, 3, and 4, representing 8 years of serial evaluation of this cohort.

COGNITIVE SCREENING AND RESCREENING

At each wave, after providing informed consent, subjects underwent in-home screening with the same cognitive tests carried out by bachelor's-degree–level research associates trained and supervised by the project neuropsychologist. The reliability of examinations was established by training and reestablished annually. Descriptions and population norms on the MoVIES cognitive test battery and test scores in subjects with and without dementia have been reported previously.25,26 The MoVIES battery incorporated the neuropsychological panel of the Consortium to Establish a Registry for Alzheimer's Disease (CERAD).27 Briefly, the battery consisted of a general mental status test, the Mini-Mental State Examination (MMSE),28 and a set of other tests of more specific cognitive domains (eg, memory, language, and constructional praxis) known to be impaired in dementia. Operational criteria for "cognitive impairment" were scores at or below the 10th percentile of the MoVIES sample on the MMSE or on at least 1 memory test and 1 other cognitive test. At each wave, both for cognitive impairment and for cognitive decline, percentiles were calculated using each subject's raw scores (and change in scores) against raw scores (or change in scores) for the whole cohort at that wave. Sensitivity and specificity of these criteria for dementia have been reported previously.22 At each wave, a clinical evaluation (see below) was performed on 3 groups: those who were "cognitively impaired," those who were "cognitively declined" (defined as a decline in scores since an earlier wave by an amount equal to or greater than the decline experienced by 95% of the sample), and a randomly selected subgroup of cognitively unimpaired controls at baseline.

IDENTIFICATION OF DEMENTIA

The standardized MoVIES procedures for clinical evaluation followed protocols of the University of Pittsburgh Alzheimer Disease Research Center and the CERAD, modified for use in the field and described in detail elsewhere.22 Briefly, subjects underwent a standardized general medical history and physical examination; detailed neurologic, psychiatric, and mental status examinations; blood tests for a hematologic, metabolic, and serologic workup; and neuroimaging when possible. Relevant medical records were obtained and abstracted. Clinical evaluations were performed by clinical research associates (registered nurse or equivalent) trained at our Alzheimer's Disease Research Center, supervised by a board-certified geriatric psychiatrist (M.G.), and blind to the screening scores. Final diagnoses were made by consensus, as per the Alzheimer's Disease Research Center protocol, among all evaluating clinicians and using all available data. Because the study started in 1987, the diagnoses of dementia were made according to DSM-III-R criteria.29 Diagnoses of probable or possible AD were made according to criteria of the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA).30 Once selected for clinical evaluation, subjects were contacted annually for follow-up evaluations. Thus, diagnoses made in previous waves were validated by data obtained during later waves. Once a diagnosis of dementia or AD (probable or possible) was made, the date of the onset of dementia or AD was estimated based on all available evidence as to the time of emergence of cognitive and functional decline.

MEASUREMENT OF DEPRESSIVE SYMPTOMS

During the screening interview, depressive symptoms were measured using the mCES-D,23 an interviewer-administered version of the original CES-D.24 In the mCES-D, subjects are asked whether or not they have experienced each symptom "most of the time," defined as 3 or more days of the previous week, so as to ascertain the persistence of depressive symptoms. The questions thus allow a yes or no response, scored as 1 or 0, for a maximum possible score of 20. Thus, the total score represents the number of persistent depressive symptoms present during most of the preceding week, a higher score reflecting more depressive symptoms. Further details23 have been reported previously.

Depressive symptoms were assessed at each of the waves (2, 3, and 4) reported here. Although a single "depressed mood" approach has shown good reliability and validity,21 in this study we have defined "depression" as a depressive symptom cluster at 1 or more wave, using a DSM-III-R–guided approach29 requiring the presence of both depressed mood and other symptoms. Thus, the presence of a depressive symptom cluster in the current analyses is defined as a cluster of mCES-D items, including depressed mood (any 1 of "felt depressed," "felt sad," "[did not] feel happy," and "could not shake off the blues") and at least 4 other symptoms ("restless sleep," "could not get going," "had trouble keeping your mind on what you were doing," "[did not] enjoy life," "[did not] feel you were just as good as others," "thought your life had been a failure," "poor appetite," "bothered by things that usually don't bother you," "felt everything you did was an effort," "[did not] feel hopeful about the future," "felt fearful," "talked less than usual," "felt lonely," "people were unfriendly," "had crying spells," or "felt that people disliked you"). This community-screening approach aims to detect depressive symptoms, rather than to diagnose depressive disorders such as major depression. The depressive cluster defined by our approach, however, had a prevalence of 8.27% among 1040 subjects aged 65 years and older, comparable with the combined rate of depressive syndromes reported from another community study by Blazer et al.2

MEASUREMENT OF SUBJECTIVE MEMORY LOSS

Self-reported (subjective) memory loss was determined by asking the subject a series of questions, including "Do you feel you remember things less well than you did 2 years ago?" The response, coded as yes or no, was used to classify subjective memory status as "loss" vs "stable." This variable was used to indicate insight (awareness of cognitive loss), which we hypothesized might be associated with both depressive symptoms and dementia, potentially confounding the relationship between depression and dementia or AD.

After a complete description of the study to the subjects, written informed consent was obtained. All data were collected according to procedures approved by the University of Pittsburgh institutional review board.

STATISTICAL METHODS

Data were analyzed using statistical software (SAS, Version 6).31 All tests were 2-tailed. Pearson χ2 tests (or Fisher exact probability tests, when appropriate) were used to test differences between groups on categorical data. Student t tests were used to test the differences between groups on continuous variables. The 95% confidence intervals (CIs) for point estimates of rates were calculated based on the normal approximation to the binomial distribution.

An overview of the study design is presented in Figure 1. To evaluate whether depression predicts the clinical onset of dementia, a Cox proportional hazards model32 was used to assess the relative risk for reaching the clinical onset of dementia or AD associated with baseline depression.

Place holder to copy figure label and caption

Design of longitudinal study on the temporal relationship of the appearance of depression to a recent onset of dementia or Alzheimer disease. The top half shows the baseline incidence of depression as a predictor of the subsequent onset of depression. The bottom half shows the appearance of depression following a recent onset of dementia.

Graphic Jump Location

To evaluate the likelihood of the appearance of new depressive symptoms following the onset of dementia or AD, a logistic regression model was used to estimate the odds ratios (ORs) of the presence of incident depression associated with a recent onset of dementia and AD. Subjective memory loss was found cross-sectionally to be associated with both dementia (P<.001) and depression (P=.01) in our cohort. To adjust for potential confounding, the models were initially fit within each stratum of self-reported memory (loss vs stable). Because ORs across the strata were not significantly different using the Woolf test for homogeneity33 (see the "Results" section), the common OR was estimated using the Mantel-Haenszel method across the strata. We also examined ORs from logistic regression models adjusted for age, sex, education, and subjective memory loss.

SAMPLE

Of the original random sample of 1366 subjects at wave 1, there were 1040 surviving participants at wave 2; 954 of these 1040 did not have dementia and provided data for the present analyses. Of these, 803 completed a wave 3 screen and 634 completed wave 3 and 4 screens. The median length of time was 801 days from wave 2 to wave 3 and 854 days from wave 3 to wave 4. Those without data at wave 3 (n=151) were considered lost to follow-up for these analyses because they were deceased (n=80), refused (n=22), relocated (n=6), were untestable due to severe physical illnesses (n=2), had incomplete mCES-D data (n=10), or were temporarily unavailable (n=31). The group lost to follow-up tended to include more men, to be older, and to have lower MMSE scores at wave 2 (P<.001) than those who were followed up (Table 1). The prevalence of depression at wave 2, however, was not significantly different (P=.34) between these 2 groups.

Table Graphic Jump LocationTable 1. Distribution of Demographic and Clinical Characteristics at Wave 2 by Follow-up Status*
BASELINE (WAVE 2) DEPRESSIVE SYMPTOMS AS PREDICTORS OF ONSET OF DEMENTIA OR AD

Of 803 subjects without dementia who had completed at least 1 subsequent screening wave (waves 3 and 4) since wave 2, incident dementia subsequently developed in 78 (including 35 with probable AD and 29 with possible AD). The mean (SD) changes in MMSE scores from waves 1 to 4 were −0.9 (2.0) for the group without dementia and −5.2 (5.6) for the group with incident dementia. The prevalence of baseline depression (at wave 2) was 7.7% among those in whom incident dementia subsequently developed between waves 2 and 4 and 6.3% among those who remained without dementia. This difference was not statistically significant (χ21=0.21; P=.65). On the other hand, dementia subsequently developed in 11.5% of subjects with baseline depression and in 9.6% of subjects without depression. In the Cox proportional hazards models, depression at wave 2 did not significantly increase the relative risk (RR) of a subsequent onset of dementia (RR=1.27, 95% CI=0.55-2.93) or AD (RR=1.28, 95% CI=0.51-3.20) after adjusting for age, sex, and education level. Significantly increased risks of dementia developing were associated with greater age (RR=1.14, 95% CI=1.10-1.19; P<.001) and less than high school education (RR=1.91, 95% CI=1.21-3.02; P=.006), but not female sex (RR=0.81, 95% CI=0.52-1.27; P=.37). The corresponding parameters for AD were age (RR=1.15, 95% CI=1.11-1.20; P<.001), lower education (RR=1.73, 95% CI=1.05-2.86; P=.03), and female sex (RR=0.84, 95% CI=0.51-1.34; P=.49). The results remained similar when using depression as a time-dependent variable.

APPEARANCE OF DEPRESSIVE SYMPTOMS FOLLOWING RECENT ONSET OF DEMENTIA

Table 2 presents the likelihood of the appearance of depressive symptoms at wave 3 following a recent onset of dementia (between waves 2 and 3) compared with that in subjects without dementia, stratified by self-reported memory. Subjects with depression at wave 2 were excluded from these analyses. Subjects with dementia include only those with a clinical onset between waves 2 and 3. Thus, the sample consists of 39 subjects with incident dementia (including 19 with probable AD and 15 with possible AD) and 712 without dementia. Within each stratum of subjective memory, the ORs of depression developing were higher among subjects with dementia and AD than among subjects without dementia. Age-, sex-, and education-adjusted ORs in each stratum showed similar patterns, although the lower bound of the 95% CI in the stable subjective memory stratum was just below 1 for dementia and AD. The ORs across strata were homogeneous (P=.73 for dementia vs nondementia and P=.86 for AD vs nondementia), ie, the associations were similar between dementia and depression regardless of subjective memory status. Therefore, common ORs (across strata) were estimated for dementia vs nondementia (OR=4.33) and for AD vs nondementia (OR=5.26). The ORs adjusted for age, sex, education, and self-reported memory showed about a 5-fold increased risk of depression developing for those with dementia and about a 6-fold increased risk for those with AD compared with those without dementia.

Table Graphic Jump LocationTable 2. Risk of Depression Developing in Early Dementia and Alzheimer Disease (AD), Stratified by Self-reported Memory Loss and Combined Across Strata (N=751)*

For comparison with other studies, similar analyses were performed using depressed mood alone (rather than the depressive symptom cluster). Results show that the adjusted RR of dementia developing was 1.15 (95% CI=0.63-2.08; P=.66) in those with depressed mood, and the adjusted OR of the appearance of a new depressed mood was 3.68 (95% CI=1.54-8.80; P=.003) in those with dementia. In addition, results from analyses using 5 or more depressive symptoms on the mCES-D (comparable to a score of ≥16 on the original CES-D) were similar (data not shown) to that using the symptom cluster.

Within a randomly sampled community-based study cohort, this study examined the temporal relationship between the appearance of a depressive symptom cluster and the estimated onset of dementia and AD. Subjects in whom incident dementia and AD developed had a significantly higher likelihood of depressive symptoms also developing. The common clinical observation that depression may be an early sign of dementia and AD has been supported by some cross-sectional studies.12,21 Follow-up of "depressive pseudodementia" in clinical and in community settings has shown that subsequent irreversible dementia frequently develops in these subjects.3,11,34,35

It is, of course, difficult to pinpoint the actual onset of most chronic diseases, including AD and depression. We used all available evidence to estimate the date of onset of cognitive and functional manifestations of dementia. This date represents the time during the brain disease when a clinically observable threshold was crossed, rather than the initiation of neurodegeneration. For our purposes, using the clinical onset of dementia, rather than the time when the diagnosis of dementia was made, provides a way to better clarify the temporal relationship between depressive symptoms and dementia. We do not, however, have data on the onset of depression beyond its minimum 1-week duration of the screening. Thus, the newly emerged depressive symptoms that some subjects reported at wave 3 might have begun before the onset of dementia and AD, although close to it because of the short 2-year interval between waves.

Depression in early AD could reflect either a biologically based clinical manifestation of brain disease, a psychological reaction of subjects to the awareness of their declining cognitive function, or both. We attempted to distinguish between those 2 possibilities by examining interactions with self-reported memory loss. As expected, we found an association between depression and the self-awareness of memory loss. Our subjects with a recent onset of dementia or AD, however, still were at a higher risk of depressive symptoms developing than subjects without dementia, independent of self-reported memory loss. The cross-sectional relationship between depression and dementia or AD may be at least partly due to depressive symptoms developing more commonly in the early course of dementia and AD than before its onset.

In our cohort, subjects with depressive symptoms at baseline did not have a significantly increased probability of the subsequent development of dementia and AD. The RR was greater than 1, however, and the CI was wide. This finding does not necessarily refute previous findings10,18 that major depression may be a risk factor for AD, because our analyses used a depressive symptom cluster rather than a clinical diagnosis of major depression. Our findings only suggest that depression preceding the onset of dementia by a few years is not a risk factor for dementia. The occurrence of depression several years earlier has not been studied in these analyses. Our negative finding may also be due to the relatively small number of depressed persons and the relatively mild depression seen in the community setting. Depressive symptoms in community samples may be qualitatively or quantitatively different from those seen in clinical samples and may not be sufficient to demonstrate an effect on the onset of dementia or AD in the population at large. The requirement that depressed mood had to be endorsed by all subjects may have eliminated purely anhedonic depression (ie, without depressed mood) as a predictor of dementia and AD.

Although depression and dementia or AD occurred together significantly more often than by chance, their co-occurrence was seen only in a small subgroup of our subjects. It may be asked whether either condition nonspecifically unmasked or increased a susceptibility to the other. This subgroup may share a distinct subtype of disease; previous studies have suggested that the development of depression in dementia is associated with the degeneration of the locus ceruleus and substantia nigra.3639 Also, 2 conditions may share common pathways through an interaction between the hippocampus and the hypothalamic-pituitary-adrenal axis.4048 Clues may emerge from trials of the effects of antidementia drugs on mood or of the effects of antidepressant drugs on cognition: studies of trichlorfon (metrifonate) and tacrine hydrochloride in AD suggest that these agents can lessen anhedonia and other symptoms of depression.4953

One concern regarding possible bias in interpreting our results is the effect of sample attrition, largely from death. Such a bias may exist, as suggested by differences in the mean MMSE score, age, and sex ratio between those observed and those lost to follow-up. This is not a large bias, however, and its effect would distort our results only slightly because we have a relatively low attrition rate (about 15%, including mortality), similar proportions of depressed subjects in those observed and those lost to follow-up, and fairly large ORs. The relatively small number of subjects with both depression and dementia, reflected by wide CIs, also prevented us from including other possible relevant variables in the analyses. We could not examine the relationships of depression with dementia other than AD because 82% of cases of dementia in this sample were diagnosed as probable or possible AD. Subjects with incident dementia may have misunderstood the self-report questions about depression and memory loss, but this would not have led systematically to either underreporting or overreporting. Furthermore, these subjects were only mildly cognitively impaired at the time of questioning (mean MMSE score, 24). Depressed subjects may also have introduced response bias by being more likely to report subjective memory loss, and some mCES-D symptoms could have been attributable to dementia rather than depression.

We have reported unique epidemiological data from a prospective, population-based study of a rural elderly population. In the population at large, the depressive symptoms associated with AD and overall dementia are prodromal or early manifestations of the dementia, rather than predictors of the subsequent development of dementia. Being community-based, these findings are at least generalizable to other rural, mainly white, populations and contribute to our broader understanding of the relationship between depression and dementia in the community.

Accepted for publication November 18, 1998.

This study was supported by grants AG00181, AG00312, AG06782, and AG07562 from the National Institute on Aging, National Institutes of Health (NIH), Bethesda, Md, and grants MH49786, MH52247, and MH01613 from the National Institute of Mental Health, NIH, Rockville, Md.

Presented in part at the 11th Annual Meeting of the American Association for Geriatric Psychiatry, San Diego, Calif, March 8-11, 1998.

We thank Steven Belle, PhD, Hiroko Dodge, PhD, and Jane Cauley, DrPH, for their valuable comments on previous drafts. We also thank the participants and staff of the Monongahela Valley Independent Elders Survey (MoVIES) project, without whom this work would not have been accomplished.

Reprints: Mary Ganguli, MD, MPH, Division of Geriatrics and Neuropsychiatry, Department of Psychiatry, Western Psychiatric Institute and Clinic, 3811 O'Hara St, Pittsburgh, PA 15213-2593 (e-mail: gangulim@vms.cis.pitt.edu).

Katzman  R The prevalence and malignancy of Alzheimer's disease: a major killer [editorial]. Arch Neurol. 1976;33217- 218
Link to Article
Blazer  DGHughes  DCGeorge  LK The epidemiology of depression in an elderly community population. Gerontologist. 1987;27281- 287
Link to Article
Alexopoulos  GSMeyers  BSYoung  RCMattis  SKakuma  T The course of geriatric depression with "reversible dementia": a controlled study. Am J Psychiatry. 1993;1501693- 1699
Emery  VOOxman  TE Update on the dementia spectrum of depression. Am J Psychiatry. 1992;149305- 317
Rovner  BWBroadhead  JSpencer  MCarson  KFolstein  MF Depression and Alzheimer's disease. Am J Psychiatry. 1989;146350- 353
Dufouil  CFuhrer  RDartigues  JFAlperovitch  A Longitudinal analysis of the association between depressive symptomatology and cognitive deterioration. Am J Epidemiol. 1996;144634- 641
Link to Article
Lichtenberg  PARoss  TMillis  SRManning  CA The relationship between depression and cognition in older adults: a cross-validation study. J Gerontol B Psychol Sci Soc Sci. 1995;50P25- P32
Link to Article
Lobo  ASaz  PMarcos  GDia  JLDe-la-Camara  C The prevalence of dementia and depression in the elderly community in a southern European population: the Zaragoza Study. Arch Gen Psychiatry. 1995;52497- 506
Link to Article
Mangione  CMSeddon  JMCook  EFKrug Jr  JHSahagian  CRCampion  EWGlynn  RJ Correlates of cognitive function scores in elderly outpatients. J Am Geriatr Soc. 1993;41491- 497
Burns  AJacoby  RLevy  R Psychiatric phenomena in Alzheimer's disease, I and III: disorders of thought content. Br J Psychiatry. 1990;15772- 7692- 94
Link to Article
Andersen  GVestergaard  KRiis  JØIngeman-Nielsen  M Dementia of depression or depression of dementia in stroke? Acta Psychiatr Scand. 1996;94272- 278
Link to Article
Broe  GAHenderson  ASCreasey  HMcCusker  EKorten  AEJorm  AFLongley  WAnthony  JC A case-control study of Alzheimer's disease in Australia. Neurology. 1990;401698- 1707
Link to Article
Merriam  AEAronson  MKGaston  PWey  SLKatz  I The psychiatric symptoms of Alzheimer's disease. J Am Geriatr Soc. 1988;367- 12
Reifler  BVLarson  ETeri  LPoulsen  M Dementia of the Alzheimer's type and depression. J Am Geriatr Soc. 1986;34855- 859
Cummings  JLRoss  WAbsher  JGornbein  JHadjiaghai  L Depressive symptoms in Alzheimer disease. Alzheimer Dis Assoc Disord. 1995;987- 93
Link to Article
Speck  CEKukull  WABrenner  DEBowen  JDMcCormick  WCTeri  LPfanschmidt  MLThompson  JDLarson  EB History of depression as a risk factor for Alzheimer's disease. Epidemiology. 1995;6366- 369
Link to Article
Knesevich  JWMartin  RLBerg  LDanziger  W Preliminary report on affective symptoms in the early stages of senile dementia of the Alzheimer type. Am J Psychiatry. 1983;140233- 235
Henderson  ASKorten  AEJacomb  PAMackinnon  AJJorm  AFChristensen  HRodgers  B The course of depression in the elderly: a longitudinal community-based study in Australia. Psychol Med. 1997;27119- 129
Link to Article
Jorm  AFvan Duijn  CMChandra  VFratiglioni  LGraves  ABHeyman  AKokmen  EKondo  KMortimer  JARocca  WAShalat  SLSoininen  HHofman  Afor the EURODEM Risk Factors Research Group, Psychiatric history and related exposures as risk factors for Alzheimer's disease. Int J Epidemiol. 1991;20 ((suppl 2)) S43- S47
Link to Article
Buntinx  FKester  ABergers  JKnottnerus  JA Is depression in elderly people followed by dementia? Age Ageing. 1996;25231- 233
Link to Article
Devanand  DPSano  MTang  MXTaylor  SGurland  BJWilder  DStern  YMayeux  R Depressed mood and the incidence of Alzheimer's disease in the elderly living in the community. Arch Gen Psychiatry. 1996;53175- 182
Link to Article
Ganguli  MBelle  SRatcliff  GSeaberg  EHuff  FJvon der Porten  KKuller  LH Sensitivity and specificity for dementia of population-based criteria for cognitive impairment: the MoVIES project. J Gerontol. 1993;48M152- M161
Link to Article
Ganguli  MGilby  JSeaberg  EBelle  S Depressive symptoms and associated factors in a rural elderly population: the MoVIES project. Am J Geriatr Psychiatry. 1995;3144- 160
Link to Article
Radloff  LS The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Measure. 1977;1385- 401
Link to Article
Ganguli  MRatcliff  GBelle  SHuff  FJKancel  MJFischer  LKuller  LH Effects of age, gender, and education on cognitive tests in an elderly rural community sample: norms from the Monongahela Valley Independent Elders Survey (MoVIES). Neuroepidemiology. 1991;1042- 52
Link to Article
Ganguli  MRatcliff  GDeKosky  S Cognitive test scores in community-based rural elderly with and without dementia. Aging Mental Health. 1997;1176- 180
Link to Article
Morris  JCHeyman  AMohs  RCHughes  JPvan Belle  GFillenbaum  GMellits  EDClark  C The Consortium to Establish a Registry for Alzheimer's Disease (CERAD), I: clinical and neuropsychological assessment of Alzheimer's disease. Neurology. 1989;391159- 1165
Link to Article
Folstein  MFFolstein  SEMcHugh  PR "Mini-Mental State": a practical method of grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12189- 198
Link to Article
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition.  Washington, DC American Psychiatric Association1987;
McKhann  GDrachman  DFolstein  MKatzman  RPrice  DStadlan  EM Clinical diagnosis of Alzheimer's disease: report of the NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer's Disease. Neurology. 1984;34939- 944
Link to Article
Not Available, SAS/STAT User's Guide, Version 6. 4th ed. Cary, NC SAS Institute Inc1989;
Cox  DR Regression models and life-tables (with discussion). J R Stat Soc Ser B. 1972;34187- 220
Rosner  B Fundamentals of Biostatistics. 4th ed. Harrisonburg, Va Duxbury Press1995;404- 413
Copeland  JRMDavidson  IADewey  MEGilmore  CLarkin  BAMcWilliam  CSaunders  PAScott  ASharma  VSullivan  C Alzheimer's disease, other dementias, depression and pseudodementia: prevalence, incidence and three-year outcome in Liverpool. Br J Psychiatry. 1992;161230- 239
Link to Article
Kral  VA The relationship between senile dementia (Alzheimer type) and depression. Can J Psychiatry. 1983;28304- 306
Zubenko  GSMoossy  J Major depression in primary dementia: clinical and neuropathologic correlates. Arch Neurol. 1988;451182- 1186
Link to Article
Forstl  HLevy  RBums  ALuthert  PCairns  N Disproportionate loss of noradrenergic and cholinergic neurons as cause of depression in Alzheimer's disease: a hypothesis. Pharmacopsychiatry. 1994;2711- 15
Link to Article
Forstl  HBums  ALuthert  PCairns  NLantos  PLevy  R Clinical and neuropathological correlates of depression in Alzheimer's disease. Psychol Med. 1992;22877- 884
Link to Article
Zweig  RMCardillo  JECohen  MGiere  SHedreen  JC The locus ceruleus and dementia in Parkinson's disease. Neurology. 1993;43986- 991
Link to Article
Sapolsky  RMKrey  LCMcEwen  B The neuroendocrinology of stress and aging: the glucocorticoid cascade hypothesis. Endocr Rev. 1986;7284- 301
Link to Article
O'Brien  JTAmes  DSchweitzer  IColman  PDesmond  PTress  B Clinical and magnetic resonance imaging correlates of hypothalamic-pituitary-adrenal axis function in depression and Alzheimer's disease. Br J Psychiatry. 1996;168679- 687
Link to Article
Jacobson  LSapolsky  R The role of the hippocampus in feedback regulation of the hypothalamic-pituitary-adrenocortical axis. Endocr Rev. 1991;12118- 134
Link to Article
Kaye  JASwihart  THowieson  DDame  AMoore  MMKamos  TCamicioli  RBall  MOken  BSexton  G Volume loss of the hippocampus and temporal lobe in healthy elderly persons destined to develop dementia. Neurology. 1997;481297- 1304
Link to Article
Reid  WBroe  GCreasey  HGrayson  DMcCusker  EBennett  HLongley  WSulway  MR Age at onset and pattern of neuropsychological impairment in mild early-stage Alzheimer's disease. Arch Neurol. 1996;531056- 1061
Link to Article
Hyman  BTVan Hoesen  GWDamasio  AR Memory-related neural systems in Alzheimer's disease: an anatomic study. Neurology. 1990;401721- 1730
Link to Article
Checkley  S Neuroendocrine mechanisms and the precipitation of depression by life events. Br J Psychiatry Suppl. 1992;No. 157- 17
Dinan  TG Glucocorticoids and the genesis of depressive illness. Br J Psychiatry. 1994;164365- 371
Link to Article
Heuser  I The hypothalamic-pituitary-adrenal system in depression. Pharmacopsychiatry. 1998;3110- 13
Link to Article
Cummings  JLCyrus  PABieber  FMas  JOrazem  JGulanski  B Metrifonate treatment of the cognitive deficits of Alzheimer's disease: Metrifonate Study Group [published correction appears in Neurology. 1998;51:332]. Neurology. 1998;501214- 1221
Link to Article
Cummings  JL Metrifonate: overview of safety and efficacy. Pharmacotherapy. 1998;18 ((pt 2)) 43- 46discussion79- 82
Kaufer  DCummings  JLChristine  D Differential neuropsychiatric symptom responses to tacrine in Alzheimer's disease: relationship to dementia severity. J Neuropsychiatry Clin Neurosci. 1998;1055- 63
Kaufer  D Beyond the cholinergic hypothesis: the effect of metrifonate and other cholinesterase inhibitors on neuropsychiatric symptoms in Alzheimer's disease. Dementia Geriatr Cogn Disord. 1998;9 ((suppl 2)) 8- 14
Link to Article
Kaufer  DICummings  JLChristine  D Effect of tacrine on behavioral symptoms in Alzheimer's disease: an open-label study. J Geriatr Psychiatry Neurol. 1996;91- 6
Link to Article

Figures

Place holder to copy figure label and caption

Design of longitudinal study on the temporal relationship of the appearance of depression to a recent onset of dementia or Alzheimer disease. The top half shows the baseline incidence of depression as a predictor of the subsequent onset of depression. The bottom half shows the appearance of depression following a recent onset of dementia.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Distribution of Demographic and Clinical Characteristics at Wave 2 by Follow-up Status*
Table Graphic Jump LocationTable 2. Risk of Depression Developing in Early Dementia and Alzheimer Disease (AD), Stratified by Self-reported Memory Loss and Combined Across Strata (N=751)*

References

Katzman  R The prevalence and malignancy of Alzheimer's disease: a major killer [editorial]. Arch Neurol. 1976;33217- 218
Link to Article
Blazer  DGHughes  DCGeorge  LK The epidemiology of depression in an elderly community population. Gerontologist. 1987;27281- 287
Link to Article
Alexopoulos  GSMeyers  BSYoung  RCMattis  SKakuma  T The course of geriatric depression with "reversible dementia": a controlled study. Am J Psychiatry. 1993;1501693- 1699
Emery  VOOxman  TE Update on the dementia spectrum of depression. Am J Psychiatry. 1992;149305- 317
Rovner  BWBroadhead  JSpencer  MCarson  KFolstein  MF Depression and Alzheimer's disease. Am J Psychiatry. 1989;146350- 353
Dufouil  CFuhrer  RDartigues  JFAlperovitch  A Longitudinal analysis of the association between depressive symptomatology and cognitive deterioration. Am J Epidemiol. 1996;144634- 641
Link to Article
Lichtenberg  PARoss  TMillis  SRManning  CA The relationship between depression and cognition in older adults: a cross-validation study. J Gerontol B Psychol Sci Soc Sci. 1995;50P25- P32
Link to Article
Lobo  ASaz  PMarcos  GDia  JLDe-la-Camara  C The prevalence of dementia and depression in the elderly community in a southern European population: the Zaragoza Study. Arch Gen Psychiatry. 1995;52497- 506
Link to Article
Mangione  CMSeddon  JMCook  EFKrug Jr  JHSahagian  CRCampion  EWGlynn  RJ Correlates of cognitive function scores in elderly outpatients. J Am Geriatr Soc. 1993;41491- 497
Burns  AJacoby  RLevy  R Psychiatric phenomena in Alzheimer's disease, I and III: disorders of thought content. Br J Psychiatry. 1990;15772- 7692- 94
Link to Article
Andersen  GVestergaard  KRiis  JØIngeman-Nielsen  M Dementia of depression or depression of dementia in stroke? Acta Psychiatr Scand. 1996;94272- 278
Link to Article
Broe  GAHenderson  ASCreasey  HMcCusker  EKorten  AEJorm  AFLongley  WAnthony  JC A case-control study of Alzheimer's disease in Australia. Neurology. 1990;401698- 1707
Link to Article
Merriam  AEAronson  MKGaston  PWey  SLKatz  I The psychiatric symptoms of Alzheimer's disease. J Am Geriatr Soc. 1988;367- 12
Reifler  BVLarson  ETeri  LPoulsen  M Dementia of the Alzheimer's type and depression. J Am Geriatr Soc. 1986;34855- 859
Cummings  JLRoss  WAbsher  JGornbein  JHadjiaghai  L Depressive symptoms in Alzheimer disease. Alzheimer Dis Assoc Disord. 1995;987- 93
Link to Article
Speck  CEKukull  WABrenner  DEBowen  JDMcCormick  WCTeri  LPfanschmidt  MLThompson  JDLarson  EB History of depression as a risk factor for Alzheimer's disease. Epidemiology. 1995;6366- 369
Link to Article
Knesevich  JWMartin  RLBerg  LDanziger  W Preliminary report on affective symptoms in the early stages of senile dementia of the Alzheimer type. Am J Psychiatry. 1983;140233- 235
Henderson  ASKorten  AEJacomb  PAMackinnon  AJJorm  AFChristensen  HRodgers  B The course of depression in the elderly: a longitudinal community-based study in Australia. Psychol Med. 1997;27119- 129
Link to Article
Jorm  AFvan Duijn  CMChandra  VFratiglioni  LGraves  ABHeyman  AKokmen  EKondo  KMortimer  JARocca  WAShalat  SLSoininen  HHofman  Afor the EURODEM Risk Factors Research Group, Psychiatric history and related exposures as risk factors for Alzheimer's disease. Int J Epidemiol. 1991;20 ((suppl 2)) S43- S47
Link to Article
Buntinx  FKester  ABergers  JKnottnerus  JA Is depression in elderly people followed by dementia? Age Ageing. 1996;25231- 233
Link to Article
Devanand  DPSano  MTang  MXTaylor  SGurland  BJWilder  DStern  YMayeux  R Depressed mood and the incidence of Alzheimer's disease in the elderly living in the community. Arch Gen Psychiatry. 1996;53175- 182
Link to Article
Ganguli  MBelle  SRatcliff  GSeaberg  EHuff  FJvon der Porten  KKuller  LH Sensitivity and specificity for dementia of population-based criteria for cognitive impairment: the MoVIES project. J Gerontol. 1993;48M152- M161
Link to Article
Ganguli  MGilby  JSeaberg  EBelle  S Depressive symptoms and associated factors in a rural elderly population: the MoVIES project. Am J Geriatr Psychiatry. 1995;3144- 160
Link to Article
Radloff  LS The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Measure. 1977;1385- 401
Link to Article
Ganguli  MRatcliff  GBelle  SHuff  FJKancel  MJFischer  LKuller  LH Effects of age, gender, and education on cognitive tests in an elderly rural community sample: norms from the Monongahela Valley Independent Elders Survey (MoVIES). Neuroepidemiology. 1991;1042- 52
Link to Article
Ganguli  MRatcliff  GDeKosky  S Cognitive test scores in community-based rural elderly with and without dementia. Aging Mental Health. 1997;1176- 180
Link to Article
Morris  JCHeyman  AMohs  RCHughes  JPvan Belle  GFillenbaum  GMellits  EDClark  C The Consortium to Establish a Registry for Alzheimer's Disease (CERAD), I: clinical and neuropsychological assessment of Alzheimer's disease. Neurology. 1989;391159- 1165
Link to Article
Folstein  MFFolstein  SEMcHugh  PR "Mini-Mental State": a practical method of grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12189- 198
Link to Article
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition.  Washington, DC American Psychiatric Association1987;
McKhann  GDrachman  DFolstein  MKatzman  RPrice  DStadlan  EM Clinical diagnosis of Alzheimer's disease: report of the NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer's Disease. Neurology. 1984;34939- 944
Link to Article
Not Available, SAS/STAT User's Guide, Version 6. 4th ed. Cary, NC SAS Institute Inc1989;
Cox  DR Regression models and life-tables (with discussion). J R Stat Soc Ser B. 1972;34187- 220
Rosner  B Fundamentals of Biostatistics. 4th ed. Harrisonburg, Va Duxbury Press1995;404- 413
Copeland  JRMDavidson  IADewey  MEGilmore  CLarkin  BAMcWilliam  CSaunders  PAScott  ASharma  VSullivan  C Alzheimer's disease, other dementias, depression and pseudodementia: prevalence, incidence and three-year outcome in Liverpool. Br J Psychiatry. 1992;161230- 239
Link to Article
Kral  VA The relationship between senile dementia (Alzheimer type) and depression. Can J Psychiatry. 1983;28304- 306
Zubenko  GSMoossy  J Major depression in primary dementia: clinical and neuropathologic correlates. Arch Neurol. 1988;451182- 1186
Link to Article
Forstl  HLevy  RBums  ALuthert  PCairns  N Disproportionate loss of noradrenergic and cholinergic neurons as cause of depression in Alzheimer's disease: a hypothesis. Pharmacopsychiatry. 1994;2711- 15
Link to Article
Forstl  HBums  ALuthert  PCairns  NLantos  PLevy  R Clinical and neuropathological correlates of depression in Alzheimer's disease. Psychol Med. 1992;22877- 884
Link to Article
Zweig  RMCardillo  JECohen  MGiere  SHedreen  JC The locus ceruleus and dementia in Parkinson's disease. Neurology. 1993;43986- 991
Link to Article
Sapolsky  RMKrey  LCMcEwen  B The neuroendocrinology of stress and aging: the glucocorticoid cascade hypothesis. Endocr Rev. 1986;7284- 301
Link to Article
O'Brien  JTAmes  DSchweitzer  IColman  PDesmond  PTress  B Clinical and magnetic resonance imaging correlates of hypothalamic-pituitary-adrenal axis function in depression and Alzheimer's disease. Br J Psychiatry. 1996;168679- 687
Link to Article
Jacobson  LSapolsky  R The role of the hippocampus in feedback regulation of the hypothalamic-pituitary-adrenocortical axis. Endocr Rev. 1991;12118- 134
Link to Article
Kaye  JASwihart  THowieson  DDame  AMoore  MMKamos  TCamicioli  RBall  MOken  BSexton  G Volume loss of the hippocampus and temporal lobe in healthy elderly persons destined to develop dementia. Neurology. 1997;481297- 1304
Link to Article
Reid  WBroe  GCreasey  HGrayson  DMcCusker  EBennett  HLongley  WSulway  MR Age at onset and pattern of neuropsychological impairment in mild early-stage Alzheimer's disease. Arch Neurol. 1996;531056- 1061
Link to Article
Hyman  BTVan Hoesen  GWDamasio  AR Memory-related neural systems in Alzheimer's disease: an anatomic study. Neurology. 1990;401721- 1730
Link to Article
Checkley  S Neuroendocrine mechanisms and the precipitation of depression by life events. Br J Psychiatry Suppl. 1992;No. 157- 17
Dinan  TG Glucocorticoids and the genesis of depressive illness. Br J Psychiatry. 1994;164365- 371
Link to Article
Heuser  I The hypothalamic-pituitary-adrenal system in depression. Pharmacopsychiatry. 1998;3110- 13
Link to Article
Cummings  JLCyrus  PABieber  FMas  JOrazem  JGulanski  B Metrifonate treatment of the cognitive deficits of Alzheimer's disease: Metrifonate Study Group [published correction appears in Neurology. 1998;51:332]. Neurology. 1998;501214- 1221
Link to Article
Cummings  JL Metrifonate: overview of safety and efficacy. Pharmacotherapy. 1998;18 ((pt 2)) 43- 46discussion79- 82
Kaufer  DCummings  JLChristine  D Differential neuropsychiatric symptom responses to tacrine in Alzheimer's disease: relationship to dementia severity. J Neuropsychiatry Clin Neurosci. 1998;1055- 63
Kaufer  D Beyond the cholinergic hypothesis: the effect of metrifonate and other cholinesterase inhibitors on neuropsychiatric symptoms in Alzheimer's disease. Dementia Geriatr Cogn Disord. 1998;9 ((suppl 2)) 8- 14
Link to Article
Kaufer  DICummings  JLChristine  D Effect of tacrine on behavioral symptoms in Alzheimer's disease: an open-label study. J Geriatr Psychiatry Neurol. 1996;91- 6
Link to Article

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