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Depressive symptoms are associated with cognitive-functional impairment in normal aging older adults (NA). However, less is known about this effect on people with mild Cognitive Impairment (MCI) and mild Alzheimer’s disease dementia (AD). We investigated this relationship along with the NA-MCI-AD continuum by reanalyzing a previously published dataset. Participants (N=274) underwent comprehensive neuropsychological assessment including measures of Executive Function, Language/Semantic Memory, Episodic Memory, Visuospatial Abilities, Activities of Daily Living (ADL), and the Geriatric Depression Scale. MANOVA, logistic regression and chi-square tests were performed to assess the association between depression and cognitive-functional performance in each group. In the NA group, depressed participants had a lower performance compared to non-depressed participants in all cognitive and functional domains. However, the same pattern was not observed in the MCI group or in AD. The results suggest a progressive loss of association between depression and worse cognitive-functional performance along the NA-MCI-AD continuum.
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ORIGINAL RESEARCH
published: 26 January 2016
doi: 10.3389/fpsyg.2015.02061
Frontiers in Psychology | www.frontiersin.org 1January 2016 | Volume 6 | Article 2061
Edited by:
Rachel M. Msetfi,
University of Limerick, Ireland
Reviewed by:
Diana Kornbrot,
University of Hertfordshire, UK
Maria Semkovska,
University of Limerick, Ireland
*Correspondence:
Jonas J. de Paula
jonasjardim@gmail.com
Specialty section:
This article was submitted to
Psychopathology,
a section of the journal
Frontiers in Psychology
Received: 12 August 2015
Accepted: 31 December 2015
Published: 26 January 2016
Citation:
de Paula JJ, Bicalho MA, Ávila RT,
Cintra MTG, Diniz BS,
Romano-Silva MA and Malloy-Diniz LF
(2016) A Reanalysis of
Cognitive-Functional Performance in
Older Adults: Investigating the
Interaction Between Normal Aging,
Mild Cognitive Impairment, Mild
Alzheimer’s Disease Dementia, and
Depression. Front. Psychol. 6:2061.
doi: 10.3389/fpsyg.2015.02061
A Reanalysis of Cognitive-Functional
Performance in Older Adults:
Investigating the Interaction Between
Normal Aging, Mild Cognitive
Impairment, Mild Alzheimer’s
Disease Dementia, and Depression
Jonas J. de Paula1, 2*, Maria A. Bicalho1, 3, 4, Rafaela T. Ávila1, 4 , Marco T. G. Cintra4,
Breno S. Diniz1, 5, Marco A. Romano-Silva 1, 5 and Leandro F. Malloy-Diniz1, 5
1Faculdade de Medicina, Instituto Nacional de Ciência e Tecnologia de Medicina Molecular, Universidade Federal de Minas
Gerais, Belo Horizonte, Brazil, 2Department of Psychology, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte,
Brazil, 3Department of Internal Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte,
Brazil, 4Reference Center for Geriatrics Instituto Jenny de Andrade Faria, Universidade Federal de Minas Gerais, Belo
Horizonte, Brazil, 5Department of Mental Health, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo
Horizonte, Brazil
Depressive symptoms are associated with cognitive-functional impairment in normal
aging older adults (NA). However, less is known about this effect on people
with mild Cognitive Impairment (MCI) and mild Alzheimer’s disease dementia
(AD). We investigated this relationship along with the NA-MCI-AD continuum by
reanalyzing a previously published dataset. Participants (N=274) underwent
comprehensive neuropsychological assessment including measures of Executive
Function, Language/Semantic Memory, Episodic Memory, Visuospatial Abilities,
Activities of Daily Living (ADL), and the Geriatric Depression Scale. MANOVA,
logistic regression and chi-square tests were performed to assess the association
between depression and cognitive-functional performance in each group. In the NA
group, depressed participants had a lower performance compared to non-depressed
participants in all cognitive and functional domains. However, the same pattern was not
observed in the MCI group or in AD. The results suggest a progressive loss of association
between depression and worse cognitive-functional performance along the NA-MCI-AD
continuum.
Keywords: older adults, depression, cognitive assessment, activities of daily living, neuropsychological
assessment, mild cognitive impairment, Alzheimer’s disease
INTRODUCTION
Depressive symptoms and cognitive impairment are common in older adults and often coexist in
an individual patient. The pattern of cognitive impairment associated with depressive symptoms
involves executive dysfunction, reduced processing speed, and deficits in episodic memory (Butters
et al., 2004; Sexton et al., 2012; de Paula et al., 2013a), while global intellectual ability, language
de Paula et al. Aging, Depression and Cognitive-Functional Performance
skills, visuospatial abilities, and semantic processing are usually
spared (Naismith et al., 2003). Furthermore, late-life depression
is a risk factor for cognitive decline and dementia, in particular
Alzheimer’s disease dementia (AD) and vascular dementia (Diniz
et al., 2013).
The neurobiological mechanisms connecting the depressive
symptoms with cognitive and functional performance are
heterogeneous. Naismith et al. (2012) reviewed evidences from
different types of studies, which discussed changes in monoamine
systems dysfunction, hormonal and immunologic changes,
inflammatory processes, and alterations on genes expression.
These different mechanisms may increase neurodegenerative
and vascular factors, which may mediate the cognitive and
functional changes associated with depression (Butters et al.,
2008). However, as reviewed by Panza et al. (2010), there
is an important overlap between depression, mild cognitive
impairment (MCI) and dementia: depression may overlap with
clinical MCI, may be a reaction to the initial symptoms of MCI,
may be one of the behavioral manifestations of MCI, or may
mask a clinical MCI. As reviewed by the authors, differences in
the studies settings and design, participants’ characteristics, and
the procedures to diagnose depression and MCI may contribute
to the inconsistency found among the studies, including the
prevalence of these conditions, its cognitive features and risk of
conversion to dementia.
Despite the well-documented impact of depressive symptoms
on cognition, the relationship of symptoms’ intensity and
cognitive performance on older adults with neurocognitive
disorders, in particular MCI and AD, is controversial. Previous
studies found no association between depressive symptoms and
neuropsychological performance in mild AD or MCI patients.
Bangen et al. (2010) assessed depressed and non-depressed AD
patients with a comprehensive neuropsychological battery and
found no differences on the cognitive performance of these
participants. On the other hand, AD patients with depression
showed a greater impairment in attention and executive function
tests when compared to non-depressed AD patients in another
study (Nakaaki et al., 2007). A recent study showed that
depressive symptoms are related to the cognitive decline in AD,
even after controlling for baseline cognitive status (Zahodne
et al., 2013). The controversy occurs on the relationship between
depression and functional performance. Depressive symptoms
are associated with poorer performance on activities of daily
living (ADL) in community-dwelling and institutionalized older
adults (Nyunt et al., 2012; Tomita and Burns, 2013; de Paula
et al., 2015a), and are important predictors of functional status
in MCI subjects (Bombin et al., 2012). The presence of cognitive
impairment and comorbid depressive symptoms seems to lead
to worse functional outcomes (Wadsworth et al., 2012). On the
other hand, different studies did not find a significant association
between depressive symptoms and functional status along the
normal aging (NA)—MCI—AD continuum (Reppermund et al.,
2011).
Altogether, these results suggest that depressive symptoms
may have a distinct impact on cognitive and functional
performance in normal aging, MCI and AD. In this sense, the
aim of the present study is to evaluate how depressive symptoms
moderate the cognitive and functional performance along this
continuum. We have reanalyzed a dataset used in previous
studies (de Paula et al., 2013b, 2014, 2015a).
MATERIALS AND METHODS
Participants
We included 274 older adults in the present study from a
convenience sample. This study was approved by the local
ethics board (registry 334/06). All subjects gave written informed
consent for participation. The caregivers of dementia patients
had also filled the consent form. The study is in accordance with
the Declaration of Helsinki. These participants and their data
were described in previously published studies (de Paula et al.,
2013b, 2014, 2015a). Participants were evaluated at the outpatient
geriatric clinic in the Federal University of Minas Gerais, Brazil.
Patients which in primary-care medical assessment had memory
complains or voluntarily asked for a cognitive assessment
were referred for the outpatient clinic, where a comprehensive
assessment was performed and they were subsequently invited
for participation. Most of these patients has a very low formal
education (below 5 years) and low socioeconomic status.
Figure 1 shows the methods used for patient’s diagnoses
and the methods used for this research. The Brazilian version
of the Mattis Dementia Rating Scale (Porto et al., 2003), the
Mini-Mental State Examination (MMSE; Folstein et al., 2001),
subtests of the CERAD Neuropsychological Battery (Morris
et al., 1989), and the Clinical Dementia Rating (CDR; Morris,
1993) were adopted. CDR scores below 1 are not indicative of
dementia, while those equal or above this value are indicative
of mild (1), moderate (2), or severe (3) dementia (Morris,
1993). Only participants with CDR scores equal or below 1 were
included. The performance on cognitive tests was adjusted for
age and educational status, based on Brazilian norms, and were
previously validated for the diagnosis of mild AD and MCI
(Brucki et al., 2003; Porto et al., 2003; Nitrini et al., 2004; Foss
et al., 2013;Table 1 shows the participants sociodemographic
characteristics, performance in cognitive tests used for diagnosis
and the median for each test based in normative data).
Cognitive status was adjudicated in expert multidisciplinary
meetings taking into account clinical, cognitive assessment,
laboratorial, and neuroimaging data when available. We
performed the diagnosis of probable AD according to the
NINCDS-ADRDA criteria (McKhann et al., 1984). It involved
cognitive impairment objectively assessed by neuropsychological
tests of episodic memory and at least on other cognitive
domain (Executive Functions, Visuospatial Abilities, and
Language/Semantic Memory) from subtests of the Brazilian
versions of the CERAD Neuropsychological Battery and the
Mattis Dementia Rating Scale; functional impairment when
compared to a previous level of performance (assessed by the
functional components of the CDR and by a clinical interview
conducted by an experienced geriatrician); insidious onset;
clear-cut report of cognitive/functional decline; and no evidence
of major neurologic or psychiatric conditions which could
respond for the symptom.
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de Paula et al. Aging, Depression and Cognitive-Functional Performance
Medical Assessment
Neuropsychological
Assessment
COGNITIVE
ASSESSMENT
Verbal Fluency
Digit Span
Rey Auditory-Verbal
Learning Test
Stick Design Test
TN-LIN (Naming)
Clock Drawing Test
Frontal Assessment
Battery
Token Test
Factor analysis to create
the measures (de Paula et
al., 2013)
Executive Functions,
Language/Semantic
Memory, Episodic
Memory and Visuospatial
Abilities.
DEPRESSION
ASSESSMENT
Geriatric Depression
Scale 15 Items
Depressed
(total score 6+)
or
Non Depressed
(Total Score <6)
FUNCTIONAL
ASSESSMENT
General Activities of Daily
Living Scale
Assessment of self-care,
instuemental-domestic and
instrumental-complex
activities of daily living.
Presence dependence
(partial or complete) from
human help to perform at
least one ADL.
Normal Aging
Mild Cognitive
Impairment
Mild AD Dementia
Clinical
Judgement
Mini-Mental
State
Examination
Mattis Dementia
Rating Scale
Clinical
Dementia Rating
Verbal Learning
(CERAD)
Measures adpated and validated for Brazilian older adults with low
formal education. We used age/education corrected cut-off /
normative values according to Brazilian studies. The classification
procedures, cutoff values and test references are described in detail
elsewhere (de Paula et al., 2013).
Protocol adopted for diagnosis Protocol adopted for research
FIGURE 1 | Description of the protocol used for participant’s diagnosis/classification, and procedures adopted for this study. Participants initially
underwent a medical and neuropsychological assessment for diagnostic procedures. In all, 274 older adults were divided into Normal Aging (NA, N=96), mild
cognitive impairment (MCI, N=85), mild dementia, and Alzheimer’s disease dementia (AD, N=93). After diagnosis, they performed the procedures of the study,
involving the assessment of cognitive functioning, depression and activities of daily living.
The diagnosis of MCI was done according to the following
criteria, adapted from Petersen et al. (2001): (1) subjective
cognitive complaint, preferably corroborated by an informant;
(2) objective impairment in the performance on specific
cognitive tests of the assessment battery (verbal learning test
from the CERAD battery and subscales from the Mattis
Dementia Rating Scale); (3) preserved global cognitive
functioning [MMSE above the cut-off for dementia adjusted
for education (as in Brucki et al., 2003), and CDR<1];
(4) preserved or minimal impairments in ADL assessed
by a clinical interview and the functional components of
the CDR; (5) not demented. The MCI patients included
on the study has symptoms and progression characteristic
of Alzheimer’s disease (amnestic presentation—deficits in
learning and recall of new information, insidious onset,
and clear-cut history of worsening of cognition by caregiver
report).
We also assessed older adults with no evidence of cognitive
impairment in the screening protocol to form a control group
without clinical history suggestive of Alzheimer’s disease. These
participants composed the normal aging group (NA). We invited
them for participation in the same institution where we assessed
the MCI and AD participants. They do not show a CDR
suggestive of dementia (CDR<1) and has cognitive tests above
the cut-off values for cognitive impairment. Participants with
subjective cognitive complaints did not have a symptomatology
or clinical course suggestive of Alzheimer’s disease (as cited in AD
and MCI participant’s description). These participants have none
or discrete functional impairment assessed in a clinical interview,
no history of neurological diseases and no sensorial or motor
impairment, which may compromise the neuropsychological
assessment.
Our final sample consisted of 274 participants: 62 NA non-
depressed, 34 NA depressed 63 MCI non-depressed, 22 MCI
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de Paula et al. Aging, Depression and Cognitive-Functional Performance
TABLE 1 | Participant’s description in sociodemographic and cognitive measures used for diagnosis.
Measures Normative dataaNA MCI AD
(median) M SD M SD M SD
Sociodemographic Age 72.61 7.76 73.18 8.46 74.57 6.65
Education 5.22 4.29 4.71 4.00 4.82 3.46
Global measures MMSE 26 25.75 3.85 23.52 3.62 20.59 3.98
DRS—Total 129 128.02 9.24 114.56 12.93 97.36 12.20
Attention DRS—Attention 35 35.34 1.41 34.71 1.75 33.61 2.17
Executive functions DRS—Initiative/Perseveration 33 32.92 4.46 28.32 5.66 22.82 5.40
Visuospatial abilities DRS—Construction 6 5.42 1.13 5.25 3.50 4.14 1.89
Language DRS—Conceptualization 32 32.26 4.92 28.48 6.46 24.23 5.26
Memory DRS—Memory 23 22.04 2.44 18.06 3.77 12.55 3.99
CERAD-VL (Total) 18 16.58 2.3 12.87 2.14 10.44 2.15
CERAD-VL (Recall) 5 5.49 1.83 2.18 1.63 2.11 1.79
CERAD-VL (Recognition) 9 8.89 1.41 6.69 1.69 3.44 2.17
NA, Normal Aging; MCI, Mild Cognitive Impairment; AD, Alzheimer’s disease dementia; MMSE, Mini-Mental State Examination; DRS, Mattis Dementia Rating Scale; CERAD-VL, Verbal
Learning Test from The Consortium to Establish a Registry for Alzheimer’s disease neuropsychological battery.
aBased in Brazilian normative/adaptation studies with older adults with similar age (±75 years) and education (±4 years).
depressed, 66 AD non-depressed, and 27 AD depressed. We
described these previous in previously published studies (de
Paula et al., 2013b, 2014, 2015a).
Assessment of Depressive Symptoms
We evaluated the presence of depression by the Brazilian
version of the Geriatric Depression Scale-15 (GDS-15; Sheikh
and Yeasavage, 1986). The cut-off score 5/6 (non-case/case)
was chosen to determine the presence of clinically significant
depressive. We adopted this cut-off due to its good validity for
detection of significant depressive symptoms in our population,
which includes patients with low socioeconomic status, low
formal education, and cognitive complaints (Almeida and
Almeida, 1999). A validation study propose this cut-off for the
detection of depression according to the DSM-IV and ICD-10
criteria (Almeida and Almeida, 1999).
The use of the GDS for the detection of depressive symptoms
and diagnosis of a depressive episode in AD patients is
controversial. Some studies report a loss of validity in patients
with dementia (Feher et al., 1992), while others do not (Brown
et al., 2007). The previous reports suggests that patients
in moderate or severe dementia may not report depressive
symptoms accurately. To reduce these biases we selected only
patients with mild dementia for the AD group (CDR1). Due
to participant’s low formal education, to ensure the questions
comprehension and validity of the report the examiner read
the questions aloud. The diagnosis of AD, MCI or NA, was
irrespective of the GDS-15 scores.
Neuropsychological Assessment
(Research Protocol)
All participants underwent a comprehensive neuropsychological
assessment protocol focused on the assessment of executive
functions, memory, language, and visuospatial cognitive
domains. The protocol was designed for the assessment of
older adults with low formal education level. We detailed these
procedures in a previous study conducted in this sample (de
Paula et al., 2013b). We have not used these neuropsychological
tests were for diagnostic purpose, and they were administered by
trained neuropsychologists.
The battery is comprised by the following tests: Digit Span
Forward and Backward (Kessels et al., 2008), verbal fluency
“fruits,” “animals,” and letter (“S”) (de Paula et al., 2013b), and
the Frontal Assessment Battery (Dubois et al., 2000) [Factor
Executive Functions]; the three components of the Laboratory of
Neuropsychological Investigations Naming Test (Malloy-Diniz
et al., 2007a) [Factor Language/Semantic Memory]; the Brazilian
Portuguese Rey Auditory-Verbal Learning Test (Malloy-Diniz
et al., 2007b) [Factor Episodic Memory]; Token Test components
of attention and comprehension (De Renzi and Faglioni, 1978;
de Paula et al., 2013b), the Clock Drawing Test (Shulman,
2000); and the Stick Design Test (Baiyewu et al., 2004)
[Factor Visuospatial Abilities]. Supplementary Table 1 shows the
participant’s performance in each neuropsychological measures,
its clinical cut-offs and maximum possible score. Supplementary
Table 2 shows the factor analysis.
Activities of Daily Living Assessment
Participant’s caregivers (usually spouses or other relatives)
answered an adapted Activities of Daily Living Scale (ADL)
based on the Lawton and Brody (1969), and Katz et al. (1970)
indexes of ADL. The scale assess 13 basic and instrumental
activities (de Paula et al., 2014). The scale consists of three ADL
aspects: Self-Care (Basic ADL), Domestic (Instrumental ADL
performed at home), and Complex (Instrumental ADL involving
activities outside home, financial management and medication
control). Scores on Basic ADL range from 0 to 10, and 0 to
8 on Domestic or Complex ADL; with lower scores indicating
greater impairment. Due to data distribution, we categorized the
functional performance (impairment ×no-impairment) based
in dependence of human help (full or partial) to perform at
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de Paula et al. Aging, Depression and Cognitive-Functional Performance
TABLE 2 | Participant’s scores in GDS-15 and performance in the neuropsychological factors obtained by factor analysis of the research protocol
stratified by group and depression.
Group Depression Statistic GDS-15 Language
semantic
Episodic
memory
Visuospatial
abilities
Executive
functions
G-ADL
self-
care
G-ADL
domestic
G-ADL
complex
G-ADL
general
Normal
aging
(N=96)
Non-depressed
(N=62)
M1.81 0.00 0.00 0.00 0.00 9.92 7.92 7.85 25.69
SD 1.30 1.00 1.00 1.00 1.00 0.38 0.33 0.51 0.93
Min-Max 0 to 5 3.54 to
1.39
1.60 to
1.14
2.62 to
1.70
2.70 to
1.63
8 to 10 6 to 8 5 to 8 20 to 26
Depressed
(N=34)
M8.94 0.99 0.79 0.87 1.63 9.97 7.24 7.00 24.21
SD 2.80 1.26 0.77 0.99 1.25 0.17 1.28 1.92 3.02
Min-Max 6 to 15 3.54 to
1.13
2.72 to
0.86
2.46 to
1.12
5.80 to
0.90
9 to 10 4 to 8 1 to 8 15 to 26
Mild
cognitive
impairment
(N=85)
Non-depressed
(N=63)
M2.06 0.75 1.30 0.87 1.19 10.00 7.41 6.94 24.35
SD 1.50 1.05 0.73 1.09 1.05 0.00 1.25 1.45 2.28
Min-Max 0 to 5 3.52 to
1.05
2.74 to
0.70
2.70 to
2.07
3.70 to
1.00
10 to 10 2 to 8 2 to 8 16 to 26
Depressed
(N=22)
M5.45 0.76 1.01 0.76 1.28 9.95 7.41 6.82 24.18
SD 4.08 0.67 0.66 0.90 1.09 0.21 1.05 1.56 2.56
Min-Max 6 to 13 2.05 to
0.40
2.19 to
0.35
2.34 to
0.80
3.30 to
0.30
9 to 10 5 to 8 3 to 8 18 to 26
Mild
Alzheimer’s
dementia
(N=93)
Non-depressed
(N=66)
M2.05 1.74 1.81 1.62 2.44 9.86 5.76 4.53 20.15
SD 1.39 1.22 0.64 1.06 1.04 0.52 2.11 2.53 4.00
Min-Max 0 to 5 3.54 to
0.78
2.78 to
0.39
2.70 to
2.58
5.20 to
0.40
7 to 10 0 to 8 0 to 8 10 to 26
Depressed
(N=27)
M8.19 1.55 1.64 1.12 1.79 9.59 5.70 3.93 19.22
SD 2.04 1.01 0.66 0.94 1.09 1.39 2.40 2.67 5.49
Min-Max 6 to 14 2.85 to
0.40
3.00 to
0.00
2.60 to
1.09
3.30 to
1.50
3 to 10 0 to 8 0 to 8 9 to 26
GDS-15, Geriatric Depression Scale 15-items; M, Mean; SD, Standard deviation; Min, Minimum; Max, maximum.
least one ADL. Supplementary Table 1 shows the participant’s
functional performance in each subscale, while Supplementary
Table 3 shows the frequency of responses by each group, stratified
by depression status, in each specific ADL.
Statistical Analysis
Prior to this study analysis, we carried out a factor analysis
with all neuropsychological measures for data reduction, as
previously reported (de Paula et al., 2013b, 2015a). Principal
axis factoring and oblique rotation were adopted. We extracted
and saved the cognitive factors as standardized (z-Scores)
variables based on non-depressed NA performance. The
procedures produced four distinct cognitive factors (Executive
Functions, Language/Semantic Memory, Episodic Memory, and
Visuospatial Abilities), used as dependent variables in the
multivariate analysis. All the factors showed adequate factor
loadings and internal consistency assessed by the Cronbach’s
Alpha (all >0.800).
For cognitive data we carried out MANOVA analysis to assess
the main effect of group (NA ×MCI ×AD) and clinically
significant depressive symptoms according to GDS cut-off
(Depressed ×Non-Depressed) on each neuropsychological
factor. Age and education were used as covariates as they
are significantly correlated with cognitive performance in
these subjects (Supplementary Table 4). We analyzed the
MANOVA residuals to check if their distribution meet the
analysis assumptions. We reported effect sizes by partial eta-
squared (η2
p). Since neither age nor education correlated
with functional measures after controlling for global cognitive
functioning in this sample (Supplementary Table 4), we adopted a
multinomial logistic regression model to compare the frequency
of impairment in each aspect of ADL. Group and depression were
added as fixed factors and chi-square tests were adopted for post-
hoc analysis. Effect sizes for chi-square tests were estimated by the
Cramér’s phi (ϕ). Post-hoc analysis comparisons were corrected
for multiple comparisons.
We performed most of the statistical procedures on the SPSS
20.0. Statistical significance was established at 0.05 (two-tailed).
Power analysis for main effects was done in G-Power software
(Faul et al., 2007). For MANOVA, our sample size (n=274) has
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de Paula et al. Aging, Depression and Cognitive-Functional Performance
Language / Semantic
Memory Episodic Memory Visuospatial Abilities Executive Functions
NA 0.93 0.76 0.76 0.76
MCI 0.23 -0.10 0.09 0.35
AD 0.11 -0.16 -0.35 -0.36
-1.00
-0.75
-0.50
-0.25
0.00
0.25
0.50
0.75
1.00
1.25
1.50 NA MCI AD
*
* * *
FIGURE 2 | Differences between the estimated marginal means (with age and education as covariates) on neuropsychological measures of depressed
and non-depressed participants in each of the three groups. When we compared depressed and non-depressed participants in each group, we found
significant differences only in NA participants. In this group, participants with clinically significant symptoms of depression showed lower performance in Executive
Functions (p<0.001,ηp2=0.37), Episodic Memory (p<0.001,ηp2=0.21), Language/Semantic Memory (p<0.001,η2
p= 0.14), and Visuospatial Abilities
(p=0.001,ηp2=0.12). Effect sizes from MCI and AD patients ranged from *p<0.01 to 0.03.
a 99% power to detect a large effect size, 86% power to detect a
moderate effect size and only 17% power to detect a small effect
size. We computed power analysis for logistic regression based in
the effect sizes represented by different odds ratio, as proposed
by Chen et al. (2010): 1.68 (small effect size), 3.47 (medium effect
size), 6.71 (large effect size). Based on our sample size we have
93% power to detect a small effect size and 99% power to detect a
small or large effect size in logistic regression.
RESULTS
Our final sample consisted of 274 participants: 62 NA non-
depressed, 34 NA depressed, 63 MCI non-depressed, 22 MCI
depressed, 66 AD non-depressed and 27 AD depressed. We did
not observe a statistically significant difference in the distribution
of depression according to diagnostic groups (χ2=2.05, p=
0.359). Table 2 shows neuropsychological and functional data for
each subgroup. Supplementary Tables 1, 2 shows the scores in
specific neuropsychological tests and functional status in each
ADL. Performance of NA participants were relatively similar to
what is expected for older adults with low formal education,
according to Brazilian normative studies, but lower than what is
expected for young adults (Brucki and Rocha, 2004; Banhato and
Nascimento, 2007; Malloy-Diniz et al., 2007b; Aprahamian et al.,
2009; Moreira et al., 2011; de Paula et al., 2015b).
Since, in previous studies we explored the effect of group
in the neuropsychological and functional measures (de Paula
et al., 2013b, 2014), we focused in the interaction between group
TABLE 3 | Interactions between group (NA ×MCI ×AD) and depression
(present ×absent) in cognitive factors and functional measures.
Cognitive and functional measures Group ×Depression
F/χ2p
Language/Semantic memorya4.61 0.011
Episodic memorya12.05 <0.001
Executive functionsa20.79 0.002
Visuospatial abilitiesa6.29 <0.001
Self-care ADLb3.00 0.223
Domestic ADLb8.31 0.016
Complex ADLb6.55 0.038
General ADLb8.84 0.012
NA, Normal aging; MCI, Mild Cognitive Impairment; AD, Alzheimer’s disease dementia;
ADL, Activities of Daily Living.
aMANOVA (group ×depression) covariating age and education for cognitive factors.
bLogistic regression (group ×depression) for functional measures.
and depression in cognitive and functional measures. We found
significant interactions for all measures (Table 3).
For cognitive measures, interactions were significant between
depressed and non-depressed NA participants, and the largest
effect size occurred in executive functions (ηp2=0.37), followed
by episodic memory (ηp2=0.21), language/semantic memory
(ηp2=0.14) and visuospatial abilities (ηp2=0.12). However,
in MCI and AD participant depression was not associated with
cognitive performance (non-significant effect sizes ranging from
ηp2<0.01 to ηp2=0.03). Differences remained significant after
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de Paula et al. Aging, Depression and Cognitive-Functional Performance
TABLE 4 | Main effect of depression in cognitive functions and group
comparison’s after covariating age and education.
Non-depressedaDepressedapηp2
NORMAL AGING
Language/Semantic
memory
0.01 (0.14) 0.94 (0.19) <0.001 0.14
Episodic memory 0.01 (0.09) 0.77 (0.12) <0.001 0.21
Visuospatial abilities 0.05 (0.12) 0.77 (0.16) 0.001 0.12
Executive functions 0.06 (012) 1.52 (0.16) <0.001 0.37
MILD COGNITIVE IMPAIRMENT
Language/Semantic
memory
0.70 (0.11) 0.92 (0.20) 0.329 0.01
Episodic memory 1.25 (0.08) 1.15 (0.14) 0.561 0.01
Visuospatial abilities 0.82 (0.11) 0.91 (0.20) 0.683 0.01
Executive functions 1.12 (0.12) 1.47 (0.20) 0.140 0.03
ALZHEIMER’S DISEASE DEMENTIA
Language/Semantic
memory
1.66 (0.14) 1.77 (0.22) 0.682 0.01
Episodic memory 1.81 (0.08) 1.65 (0.13) 0.324 0.01
Visuospatial abilities 1.58 (0.13) 1.22 (0.20) 0.154 0.02
Executive functions 2.35 (0.13) 1.99 (0.20) 0.146 0.02
aEstimated marginal mean (standard error).
multiple comparisons correction. These data is show in Table 4
and Figure 2.
The interaction for group ×depression in self-care ADL was
not significant (p=0.223). For instrumental-domestic activities,
we found a significant difference in the NA group (ϕ=0.341),
where difficulties were more frequent in depressed (32%) than
non-depressed (6%) participants. The same pattern occurred for
instrumental-complex activities (ϕ=0.314), where depressed
patients (35%) showed more difficulties than non-depressed
participants (10%). Considering all the 13 activities, a significant
difference also occurred in the NA group (ϕ=0.333), where
depressed participants were more likely to show impairment in at
least one activity (47%) than non-depressed participants (16%).
However, for both MCI and AD participants, no significant
differences were found on instrumental-domestic, instrumental-
complex, or in the general index of ADL (non-significant effect
sizes ranging from ϕ=0.004 to ϕ=0.185). Differences remained
significant after multiple comparisons correction. Table 5 and
Figure 3 show these analyses.
DISCUSSION
The present results suggest that the association of depressive
symptoms with cognitive and functional performance is
dependent on the degree of global impairment across the
NA-MCI-AD continuum. The effect of depression on cognitive
functions such as episodic memory, language, executive
functions, and visuospatial abilities, was more intense in the
NA group. Depressive symptoms in subjects with MCI or AD
had no significant effect on cognitive performance, with very
low effect sizes. We found an association between depression
and functional measures only in the NA group, and this effect
5% 6% 10%
16%
3%
32%
35%
47%
0%
20%
40%
60%
80%
100%
Self-Care ADL Domestic ADL Complex ADL Gen eral ADL
Normal Aging
Normal Aging Normal Aging
0%
29%
49%
56%
5%
27%
45% 45%
0%
20%
40%
60%
80%
100%
Self-Care ADL Domestic ADL Complex ADL General ADL
Mild Cognitive Impairment
8%
73%
85%
91%
15%
70%
85% 89%
0%
20%
40%
60%
80%
100%
Self-Care ADL Domestic ADL Complex ADL General ADL
Alzheimer's disease dementia
p=0.001
φ=0.341
p=0.002
φ=0.314
p=0.001
φ=0.333
FIGURE 3 | Associations between the frequency deficits in different
types of ADL and the presence of clinically significant symptoms of
depression in each group. We found significant differences in frequency of
impairment (partial or complete) of at least one ADL and the presence of
clinically significant symptoms of depression only in the NA group. Impairment
in instrumental-domestic ADL (p=0.001,ϕ=0.341), instrumental-complex
ADL (p=0.002,ϕ=0.314), and ADL general (p=0.001,ϕ=0.333) were
more frequent in participants with clinically significant depressive Symptoms.
The association between depression and ADL was found in MCI or AD
participants (effect sizes ranged from 0.004 to 0.185).
occurred in instrumental-domestic, instrumental-complex, and
general-ADL. In this sense, our results suggest that depression
not be strongly associated with a worse cognitive and functional
phenotype in patients with MCI or AD.
Frontiers in Psychology | www.frontiersin.org 7January 2016 | Volume 6 | Article 2061
de Paula et al. Aging, Depression and Cognitive-Functional Performance
TABLE 5 | Frequency of impairment in at least one activity of daily living in each group and group comparison’s (chi-square test) between depressed and
non-depressed participants.
NA MCI AD
ImpairmentaND D ND D ND D
Self-care ADL No 95% 97% 100% 95% 92% 85%
Yes 5% 3% 0% 5% 8% 15%
χ2=0.20 χ2=2.89 χ2=1.15
p=0.656 p=0.259 p=0.284
ϕ=0.045 ϕ=0.185 ϕ=0.024
Domestic ADL No 94% 68% 71% 73% 27% 30%
Yes 6% 32% 29% 27% 73% 70%
χ2=11.17 χ2=0.01 χ2=0.05
p=0.001 p=0.907 p=0.818
ϕ=0.341 ϕ=0.013 ϕ=0.185
Complex ADL No 90% 65% 51% 55% 15% 15%
Yes 10% 35% 49% 45% 85% 85%
χ2=9.46 χ2=0.09 χ2=0.01
p=0.002 p=0.762 p=0.967
ϕ=0.314 ϕ=0.033 ϕ=0.004
General ADL No 84% 53% 44% 55% 9% 11%
Yes 16% 47% 56% 45% 91% 89%
χ2=10.64 χ2=0.67 χ2=0.09
p=0.001 p=0.414 p=0.765
ϕ=0.333 ϕ=0.089 ϕ=0.031
NA, Normal Aging; MCI, Mild Cognitive Impairment; AD, Alzheimer’s disease dementia; D, Depressed; ND, Non-Depressed; ADL, Activities of daily living.
aRequires partial need of human help to perform at least one ADL of each group.
The effect of depressive symptoms was more pronounced in
executive function in comparison to the other cognitive domains.
Executive dysfunction impairment is an important feature of
late-life depression and is associated with negative outcomes such
as suicide behavior, development of neuropsychiatric symptoms,
and higher risk of dementia (Moreira et al., 2012; Richard-
Devantoy et al., 2012; Diniz et al., 2013). As the integrity of
the fronto-striatal circuitry and dopaminergic neurotransmission
are main correlates of executive functions, we can hypothesize
that these neurobiological correlates are particularly vulnerable
to the deleterious effects of depression (Fitzgerald et al., 2008;
Malloy-Diniz et al., 2013). In this sense, cognitive interventions,
neuromodulation, psychotherapy, or pharmacological treatment
may restore or reduce the intensity of both cognitive deficits and
psychiatric symptoms (Lenze et al., 2014; Mackin et al., 2014;
Diamond et al., 2015). However, this is a complex relationship,
since improvement of depressive symptoms may not necessarily
lead to remission in cognitive deficits (Nebes et al., 2003; Bhalla
et al., 2006) or improvement in cognitive functioning may not
reduce symptoms of depression (McDermott and Gray, 2012).
Cognitive impairment in depression has been associated to
distinct neurobiological changes. Depression is associated with
the hypothalamic-pituitary-adrenal axis dysfunction, a factor
related to higher secretion of glucocorticoids (Butters et al.,
2008). This mechanism relates to hippocampal atrophy and
may be a neurobiological causal factor to the episodic memory
impairment in depressed subjects (Panza et al., 2010; Naismith
et al., 2012). Another important mechanism with may explain
the current findings is the increase of vascular burden, especially
white matter lesions, found in depressed subjects (Tham et al.,
2011). These lesions may reflect on the overall brain functioning
by ischemia or the disruption of frontostriatal connections,
aspects closely related to the executive functions and processing
speed (Royall et al., 2002). A third pathway relates to amyloid
burden: late-life depression is associated to an increase of
β-amyloid, a factor associated with the severity of cognitive
impairment and overall severity of depression (Piccinni et al.,
2013).
However, similar changes were reported in MCI subjects
and patients with AD (Forlenza et al., 2010; Panza et al.,
2010). Therefore, the presence of these neurobiological
changes in subjects with depressive symptoms and MCI/AD
seems not to confer a synergic or an additive effect on
cognitive performance in older adults. On the other hand,
the emergence of neurodegenerative changes in the MCI/AD
continuum may reduce the impact of depression-related
neurobiological changes on cognitive performance. Additional
studies, including neuroimaging and biological markers, are
necessary to disentangle the mechanisms by which depressive
symptoms moderate cognitive performance in these subjects.
We evaluated the impact of depressive symptoms over a broad
range of ADLs. Depressive symptoms were associated with worse
performance only on instrumental-domestic or instrumental-
complex ADL. This pattern of association might be explained by
Frontiers in Psychology | www.frontiersin.org 8January 2016 | Volume 6 | Article 2061
de Paula et al. Aging, Depression and Cognitive-Functional Performance
the complex nature of the tasks by itself, which my demand more
pronounced involvement motivation, emotional regulation, and
cognitive control. In addition, the effects of depression in
ADL seems weaker than its impact in cognitive functioning.
Our results are in line with recent reports of the literature
(Reppermund et al., 2011; Park et al., 2013; de Paula et al.,
2015a). Previous studies also showed no significant impact of
depression in ADLs. Methodological differences between studies
may help to explain the effects results, in particular sample
setting (population-based, memory clinic and nursing homes)
and different strategies and scales to assess ADLs (objective
assessment, informant-based assessment; Reppermund et al.,
2011). Given the importance of this topic, additional studies are
necessary to address the impact of late-life depression in the
performance on ADLs.
The present study should be viewed in light of some
limitations, which hinders its generalization to other populations.
First, we used the GDS-15 to evaluate depressive symptoms
and we did not carry out a structured psychiatric interview to
confirm the presence of a depressive episode. Despite the fact
that GDS-15 is widely used in clinical and research settings, there
is criticism about the use of the GDS-15 on the assessment of
depressive symptoms in AD and other dementias. Therefore,
we might have misidentified cases of depression in AD group,
what may have influenced the present results. The cross-sectional
design and the recruitment of participants among individuals
referred to a cognitive evaluation due to memory complaints
also limit the generalization of the present results. On the other
hand, cognitive performance was evaluated by a comprehensive
neuropsychological protocol, which was not used to define
each subject diagnosis. This is a major strength of our study
and reduces the risk of circularity and bias in the present
analyses.
In conclusion, the present study reanalyzed a previously
published dataset and showed a significant association of
depressive symptoms on multiples domains of cognition
only in older subjects with no evidence of global cognitive
impairment. In addition, the effect of depressive symptoms on
functional performance was restricted to domestic and complex
ADLs. Additional studies, with a prospective design and with
population-based samples are necessary to replicate the present
findings.
FUNDING
This work was supported by the following grants: APQ-
01972/12-10, APQ-02755-10, APQ-04706-10, CBB-APQ-00075-
09 from FAPEMIG, and 573646/2008-2 from CNPq. The funders
had no role in study design, data collection, analysis, decision to
publish, or preparation of the manuscript.
SUPPLEMENTARY MATERIAL
The Supplementary Material for this article can be found
online at: http://journal.frontiersin.org/article/10.3389/fpsyg.
2015.02061
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Conflict of Interest Statement: The authors declare that the research was
conducted in the absence of any commercial or financial relationships that could
be construed as a potential conflict of interest.
The reviewer, Maria Semkovska, and the handling Editor declared their shared
affiliation, and the handling Editor states that the process nevertheless met the
standards of a fair and objective review.
Copyright © 2016 de Paula, Bicalho, Ávila, Cintra, Diniz, Romano-Silva and Malloy-
Diniz. This is an open-access article distributed under the terms of the Creative
Commons Attribution License (CC BY). The use, distribution or reproduction in
other forums is permitted, provided the original author(s) or licensor are credited
and that the original publication in this journal is cited, in accordance with accepted
academic practice. No use, distribution or reproduction is permitted which does not
comply with these terms.
Frontiers in Psychology | www.frontiersin.org 11 January 2016 | Volume 6 | Article 2061
... An increasing number of dementia studies have used a person's ability to perform everyday activities to predict cognitive decline [5,8,9,26]. The neurological process of cognitive impairment occurs gradually [5], and it may take two to four years before a self-report restriction in activities of daily living [5,27]. ...
... The mechanism by which cognitive decline in the presence of depressive symptoms manifests in declined daily functioning remains unclear [18]. A cross-sectional study amongst 274 older adults in Brazil across the cognitive function levels revealed that participants with depression have lower performance than those who did not have depression in the cognitively healthy group but not in older adults with MCI, dementia, or AD [26]. This study suggests a progressive loss of association between depression and poorer cognition along the cognitive functioning continuum (cog-nitively healthy-MCI-dementia/AD), adding to the challenges of dementia diagnosis based on everyday functioning. ...
... Eight studies were included in the final analysis, all of which were published articles [5,6,8,9,18,22,24,26]. Of these, four explored participants' activities of daily living in people with early-stage cognitive decline or at high risk for dementia [6,8,9,22], while the remaining articles focused on depressive symptoms affecting the activities of daily living in older adults with cognitive decline or Alzheimer's disease [5,18,24,26]. ...
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(1) Background: This scoping review identifies subjective cognitive decline (SCD) indicators in ADLs and instrumental activities of daily living (IADLs) in older adults with depressive symptoms using the WHO International Classification of Functioning, Disability, and Health (ICF). (2) Methods: We searched Medline via Ebscohost, Pubmed, and PsycINFO for articles published on activities of daily living (ADL) indicators of SCD in older adults with depressive symptoms, published in English language journals from January 2011 to November 2021. Following the flow diagram, 2032 titles and abstracts were screened for relevance based on the Population, Concept, and Context inclusion and exclusion criteria. (3) Results: Eight articles provided evidence about the ADL indicators of SCD in older adults with depressive symptoms. The analysis yielded indicators based on low and high cognitively demanding tasks assessed on five different scales. Framed on the ICF categorization and coding system, the SCD-ADL indicators are personal care, mobility, and general tasks and demands; SCD-IADL indicators are mobility, general tasks and demands, learning and applying knowledge, domestic life, communication, major life areas, and community, social, and civic life. (4) Conclusion: Highly cognitively demanding activities present more difficulties for individuals with SCD, making IADLs a stronger predictor of SCD than ADLs.
... In cross-sectional studies, LLD is associated with worse performance across a variety of cognitive domains, including processing speed, visuospatial abilities, episodic memory, verbal fluency, and executive functions [12,13]. Of these, deficits in processing speed and executive functions appear most prominent [7,14] and may mediate dysfunction observed in other cognitive domains [7]. ...
... In summary, LLD is associated with cognitive dysfunction across a variety of domains, including processing speed, visuospatial abilities, episodic memory, verbal fluency, and executive functions [9][10][11][12][13][14][15]. This has been shown in both crosssectional and longitudinal studies, and is particularly prominent for processing speed and executive functions. ...
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Purpose of Review Both clinical and subthreshold depression in older adults are associated with cognitive dysfunction. This review summarizes the latest literature on patterns of cognitive functioning in late-life depression (LLD), including moderators of the relationship between depression and cognitive functioning and underlying neurobiological mechanisms. Recent Findings LLD is associated with cognitive dysfunction across multiple domains, particularly processing speed and executive functions. This relationship is moderated by demographic and clinical variables such as sex, race, age of onset, and severity of different symptom dimensions of depression. The impact of depression treatment on cognitive deficits in LLD differs across treatment approaches, but overall LLD is associated with persistent cognitive deficits after depression remission. Summary Clarifying treatments with dual mood and cognitive benefits is an important area for future research. Our understanding of and treatment for cognitive deficits in LLD will also benefit from additional work that examines clinical and demographic contributions.
... Cognitive domains were assessed by various tests, including episodic memory [Wechsler Memory Scale-Revised Logical Memory (WMS-RLM); Wang et al., 2015], executive function [Trail Making Test Part A&B (TMT A&B); Perrochon and Kemoun, 2014], the Symbol Digit Modalities Test (SDMT; Cherbuin et al., 2010), and the Forward and Backward Digit Span Task (DST) Chinese version (Laures-Gore et al., 2011). Abilities of daily living were measured by the Functional Activities Questionnaire (FAQ), quality of life was measured by the 36-Item Short-Form Health Survey (SF-36; Lam et al., 1998;Hsiao et al., 2015), and depression was assessed using the Geriatric Depression Scale (GDS-15;de Paula et al., 2016). All these assessments were completed at baseline and after 3 months of dance intervention. ...
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As an intermediate state between normal aging and dementia, mild cognitive impairment (MCI), especially amnestic MCI (aMCI), is a key stage in the prevention and intervention of Alzheimer’s disease (AD). Whether dancing could increase the hippocampal volume of seniors with aMCI remains debatable. The aim of this study was to investigate the influence of aerobic dance on hippocampal volume and cognition after 3 months of aerobic dance in older adults with aMCI. In this randomized controlled trial, 68 elderly people with aMCI were randomized to either the aerobic dance group or the control group using a 1:1 allocation ratio. Ultimately, 62 of 68 participants completed this study, and the MRI data of 54 participants were included. A specially designed aerobic dance routine was performed by the dance group three times per week for 3 months, and all participants received monthly healthcare education after inclusion. MRI with a 3.0T MRI scanner and cognitive assessments were performed before and after intervention. High-resolution three-dimensional (3D) T1-weighted anatomical images were acquired for the analysis of hippocampal volume. A total of 35 participants (mean age: 71.51 ± 6.62 years) were randomized into the aerobic dance group and 33 participants (mean age: 69.82 ± 7.74 years) into the control group. A multiple linear regression model was used to detect the association between intervention and the difference of hippocampal volumes as well as the change of cognitive scores at baseline and after 3 months. The intervention group showed greater right hippocampal volume (β [95% CI]: 0.379 [0.117, 0.488], p = 0.002) and total hippocampal volume (β [95% CI]: 0.344 [0.082, 0.446], p = 0.005) compared to the control group. No significant association of age or gender was found with unilateral or global hippocampal volume. There was a correlation between episodic memory and intervention, as the intervention group showed a higher Wechsler Memory Scale-Revised Logical Memory (WMS-RLM) score (β [95% CI]: 0.326 [1.005, 6.773], p = 0.009). Furthermore, an increase in age may cause a decrease in the Mini-Mental State Examination (MMSE) score (β [95% CI]: −0.366 [−0.151, −0.034], p = 0.002). In conclusion, 3 months of aerobic dance could increase the right and total hippocampal volumes and improve episodic memory in elderly persons with aMCI. Clinical Trial Registration: This study was registered on the Chinese Clinical Trial Registry [www.chictr.org.cn], identifier [ChiCTR-INR-15007420].
... Second, we used the GDS-15 to evaluate depressive symptoms to confirm a depressive episode and exclude participants. Although being used GDS-15 in research, there are criticisms about evaluating depressive symptoms in dementias (de Paula et al., 2016). Another essential point refers to low educational levels. ...
... Thus, characterization of the pattern of cognitive deficits is sufficient to delineate the profile of cognitive impairment due to DD in younger subjects. Studies in older persons often assume the same procedure and diagnose the cause of cognitive impairment on clinical and neuropsychological grounds [4][5][6] despite other studies reporting that distinction between cognitive impairment due to DD and cognitive impairment due to AD is difficult if not impossible on clinical and neuropsychological grounds [7,8]. ...
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Objectives Depressive symptoms and cognitive impairment often concur in older persons. Differentiating the cause of cognitive impairment in older persons with Depressive Disorder (DD) from other diseases such as Alzheimer’s Disease (AD) is challenging. The goal of this study was to characterize cognitive impairment in older persons with DD. Design Cross-sectional retrospective observational clinical cohort study using patient records from 2014 to 2018. Setting Gerontopsychiatric services of Ulm University at Bezirkskrankenhaus Günzburg serving as primary psychiatric care institution and tertiary referral center for psychiatric care for older persons. Partcipants DD was diagnosed according to ICD-10 criteria. When indicated by the medical history or neuropsychological assessment further diagnostic procedures were initiated. Cerebrospinal fluid (CSF) tap was routinely the first additional procedure. If patients did not consent to CSF tap or contraindications were present, ¹⁸F-fluordesoxyglucose-PET (FDG-PET) or Amyloid-PET (Am-PET) were performed. Materials and methods Extensive neuropsychological test battery to assess cognitive profile. Results 457 subjects were diagnosed with DD (DD-all; age 50–94; 159 males, 298 females). Biomarkers were assessed in 176 persons; in 90 of these subjects AD-biomarkers were negative (DD-BM-; age 54–89; 40 males, 50 females), and in 86 subjects at least one biomarker was compatible with AD (DD-BM+; age 60–90; 31 males, 55 females). Cognitive performance was below healthy controls (HC; n = 56; age 50–80; 30 males, 26 females) for all groups of patients with DD. With case-control matching of HC and DD-BM- we find that executive functions are impaired in about one out of three and delayed recall in about two out of three patients with DD. Conclusion Cognitive impairment is frequent in older persons with DD. Cognitive profile in older patients with DD without and with biomarkers of AD is not distinguishable. Therefore, cognitive impairment due to DD should be diagnosed after exclusion of comorbid AD.
... Due to these compromised resources, individuals with PD-MCI may be more acutely vulnerable to the negative effects of anxiety, depression, and apathy on cognitive performance. Conversely, mood symptoms may only have a minimal association with cognitive performance in PD-MCI patients as the accumulated neurodegenerative changes in seen in MCI may reduce depression-related neurobiological changes on cognitive performance, as was found in a study in a non-PD sample of cognitively healthy older adults, older adults with MCI, and patients with AD. 20 Elucidating the moderating role of PD-MCI is important as this may increase our understanding of the complex associations between psychiatric symptoms and cognitive performance and potentially aid in identifying temporal windows for when interventions may be most impactful. ...
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Objective: Mild cognitive impairment (MCI) and psychiatric symptoms (anxiety, depression, and apathy) are common in Parkinson's disease (PD). While studies have supported the association between psychiatric symptoms and cognitive performance in PD, it is unclear if the magnitude of link between psychiatric symptoms and cognitive health is stronger by MCI status. The purpose of this study was to examine the association between cognitive performance and psychiatric symptoms in PD and whether MCI status moderates this association. Methods/design: Participants (N=187) completed a comprehensive neuropsychological assessment that included measures of attention, language, executive function (EF), visuospatial ability, episodic memory, and psychiatric symptoms. Participants were classified as PD-MCI (N = 73) or PD-normal cognition (NC; N=114). Linear regression analyses were conducted to examine the association between psychiatric symptoms and cognitive performance and the moderating effect of PD-MCI status. Results: There were no differences in mean psychiatric symptoms between PD-MCI and PD-NC. Psychiatric symptoms were predominantly associated with worse EF. The magnitude of the association between anxiety and worse EF was larger in participants with PD-MCI compared to PD-NC. A multivariable regression analysis examining the independent contributions of each symptom demonstrated the most robust association between EF and anxiety. Conclusions: Symptoms of anxiety, depression, and apathy are associated with worse executive functioning in individuals with PD. PD-MCI may be important in moderating the association between cognitive performance, specifically anxiety, and EF. Factors that promote cognitive resilience may serve as key therapeutic modalities in managing neuropsychiatric symptoms in PD. This article is protected by copyright. All rights reserved.
... The 15-item Geriatric Depression Scale (GDS-15) was used to assess the patient's subjective experience of depression in the last week. 40 Each item in the GDS-15 was scored dichotomously (yes/no). The GDS-15 score ranged from 0 to 15, with higher scores indicating more depressive symptoms. ...
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Background Mild cognitive impairment (MCI) is known as a transitional stage or phase between normal aging and dementia. In addition, it is associated with an increased risk of dementia. Research has shown that moderate-intensity exercise is associated with a decreased risk of cognitive impairment. Two recent studies demonstrated that dance interventions are associated with improved cognitive function in the elderly with MCI. Purpose We evaluated the effect of a moderate-intensity aerobic dance routine on the cognitive function in patients with MCI. Patients and methods This is a single-blind randomized controlled trial. Sixty MCI patients were randomized to receive either treatment (aerobic dance routine + usual care) or control (usual care only) for 3 months. All patients received usual care for an additional 3 months thereafter. The aerobic dance routine was a specially designed dance routine which involved cognitive effort for patients to memorize the complex movements. Wechsler memory scale-revised logical memory (WMS-R LM) and event-related evoked potentials (ERPs) P300 latency were used to assess patients’ cognitive function at baseline, 3 months, and 6 months. Results Twenty-nine patients received exercise therapy and 31 patients received usual care. Patients in the treatment group showed a greater improvement in memory (difference in WMS-R LM changes over 3 months 4.6; 95% CI 2.2, 7.0; p<0.001) and processing speed (difference in P300 latency changes over 6 months −20.0; 95% CI=−39.5, −0.4; p<0.05) compared to control. Conclusion This dance routine improves cognitive function, especially episodic memory and processing speed, in MCI patients and merits promotion in communities.
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Background: Depression in the elderly population has been identified as a significant public health problem associated with adverse outcomes such as decreased quality of life, cognitive decline, and increased rates of suicide. We aimed to determine the prevalence and factors associated with depressive symptoms among geriatric population in Moshi district council, northern Tanzania. Methods: This community-based cross-sectional study was conducted in Moshi rural district, northern Tanzania, between June and July 2019. A multi-stage sampling technique was used to recruit 304 elders aged 60 or more years. We used geriatric depression scale (GDS-15) to assess depression. Generalized linear model with Poisson family and log link function was used to estimate prevalence ratio (PR) and the corresponding 95% confidence intervals for factors associated with geriatric depressive symptoms. Results: A total of 304 participants were enrolled, the median age (interquartile range) 67 (62-75.5 years), and about half (51%) were females. The prevalence of geriatric depressive symptoms was 44.4%. Elders with a self-reported history of cognitive impairment had higher prevalence of depressive symptoms (PR = 1.66, 95%CI 1.16, 2.38) while elders with intermediate (PR = 0.56, 95%CI 0.38, 0.82) and strong social support (PR = 0.27, 95%CI 0.17, 0.44) were less likely to have depressive symptoms compared to those with no available social support. Conclusions: Nearly one in every two elders had geriatric depressive symptoms. Depressive symptoms were associated with self-reported history of cognitive impairment and availability of social support. We recommend community screening, awareness creation, and social support interventions for early identification and management of depressive symptoms in this population.
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Objective: Using a multimethod approach, this study assessed the relationship between patient and informant ratings of depression in Alzheimer's disease (AD) in a manner that better represents the progressive course of AD, and allows for elucidation of specific cognitive domains that may explain changes in respondent agreement. Method: Case data (N = 16,297) were provided by the National Alzheimer's Coordinating Center (NACC). A series of contingency analyses were performed to assess the relationship between patient and informant agreement across levels of impairment in individuals with AD. Patients and informants were placed into groups (i.e., not impaired, mild impairment, moderate impairment, severe impairment) based on patients' performance on multiple indicators of global cognitive functioning, as well as measures of attention, working memory, processing speed, executive functioning, language, and episodic learning and memory. Results: Across measures, greater impairment was significantly (p < .001) associated with decreases in patient-informant congruence and increases in rates of patients denying depression when informants endorsed observing features of the same. These inconsistencies were most pronounced in the mildest stages of impairment. For a subset of the sample, rates of patients reporting depressive symptoms when informants denied observing the same also increased alongside worsening impairment. Incremental impairment in episodic learning (χ² = 805.25) and memory (χ² = 856.94) performance were most closely associated with decreases in respondent agreement. Patient-informant relationship type did not appear to mediate the response patterns observed. Conclusions: Mild impairment in AD patients, particularly in episodic learning and memory functioning, is significantly associated with decreases in patient-informant agreement regarding the presence of depressive symptoms. These results suggest that even at the earliest stages of AD informant reports should be used to corroborate patients' reporting. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
Chapter
Older adults are one of the fastest growing segments of the US population. In 2016, more than 48 million people over age 65 lived in the country, accounting for over 15% of the population and representing a 30% increase since 2005 (Administration on Aging, 2016a, 2016b; United States Census, 2016). Moreover, by 2060, the number of adults living in the USA who are over age 65 is expected to double, reaching an anticipated 98 million (Administration on Aging, 2016a, 2016b). This growth is due in large part to increases in ethnic minority populations. Since 2005, racial and ethnic minority populations in the country have increased from 6.7 million to over 11 million, with projections estimating an increase to 21 million by 2030 (Administration on Aging, 2016a, 2016b). Individuals of racial or ethnic backgrounds make up a significant portion of the total population over age 65; in 2015, 22% of older adults identified as an ethnicity other than “White,” with the highest proportions being African-American (not Hispanic) or Hispanic (Administration on Aging, 2016a, 2016b). When working with older adults, clinicians must be sensitive to the increasingly heterogeneous nature of this population, a point which will be further discussed in this chapter.
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Background: The aim of our study was to review the literature on the relationship between executive dysfunction (EDF) and the behavioral and psychological symptoms of dementia (BPSD). Material/Methods: We searched for papers that addressed one or both of two questions: a) is there a causal relationship between EDF and BPSD?; b) What are the main hypotheses or theoretical models that explain this relationship? A systematic search was made identify all possibly relevant papers on the Scopus-Elsevier and PubMed databases, using an algorithm with the keywords most often used to search for references on EDF and BPSD. Results: We found 112 works in Scopus-Elsevier and 59 in PubMed; 20 were repeated, resulting in 151 distinct publications. We excluded 143 of these because they did not consider EDF as an independent variable and BPSD as a dependent variable. Five more works came out of a reverse search on the bibliography from the 8 remaining papers, resulting in 13 works for our review. Two groups were formed according to their investigative design to establish the relationship between EDF and BPSD. Conclusions: The studies generally found an association between EDF and BPSD, but few of them have investigated the nature of this relationship, with little clarification of the mechanism through which the former contributes to the emergence of the latter.
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Objective: To expand norms for the Mattis Dementia Rating Scale (DRS) for the Brazilian middle-age and elderly populations. Methods: The DRS was administered to 502 individuals without cognitive deficits, 312 women and 190 men, aged 50 years or over and with educational level ranging from 0 to 13 years or more. The sample was composed of subjects who participated in other studies, from Caeté (Minas Gerais state), Ribeirão Preto (São Paulo state) and São Paulo (São Paulo state). Participants were divided into four schooling groups (illiterate, 1 to 4 years, 5 to 12 years and 13 years or more). The subjects were divided into four groups according to age (50 to 60, 61 to 70, 71 to 80, and 80 years or over). Results: Normative data for DRS scores are expressed as percentile values. The group with lowest schooling and subjects older than 80 years had the worst scores. Conclusion: As expected, age and education were strongly correlated with DRS scores. Illiterates and older old individuals performed worse than the other groups. These data might help to improve the accuracy of the diagnosis of cognitive impairment and dementia in Brazilian middle-age and elderly populations.
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Objective: Verbal fluency tests are widely used for the assessment of executive functions. However, traditional versions of the test depend on several cognitive factors beyond these components. The aim of this study was to evaluate the associations of a modified version of the verbal fluency with specific measures of executive functions. Methods: Sixty adults were evaluated using traditional versions of verbal fluency (animals/fruits) and a modified condition where subjects must switch between animals and fruits. Processing speed, semantic abilities, psychiatric symptoms and executive functions were also assessed. Results: Partial correlations between the verbal fluency tests and measures of executive functions, controlled for demographic, cognitive and psychiatric symptoms, suggest that cognitive flexibility has 9% shared variance with the verbal fluency test - category animals, 2 % with category fruits, 8% with total words in switching condition, and 20% with total correct word-pairs produced in switching condition. The other aspects of executive functions during the task had shared variance of between 1% and 7% with the verbal fluency tasks. Conclusion: The results suggest that correct word-pairs produced in switching verbal fluency may be a more specific measure for evaluating cognitive flexibility compared to other versions of verbal fluency.
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Cognitive functioning influences activities of daily living (ADL). However, studies reporting the association between ADL and neuropsychological performance show inconsistent results regarding what specific cognitive domains are related to each specific functional domains. Additionally, whether depressive symptoms are associated with a worse functional performance in older adults is still under explored. We investigated if specific cognitive domains and depressive symptoms would affect different aspects of ADL. Participants were 274 older adults (96 normal aging participants, 85 patients with mild cognitive impairment, and 93 patients probable with mild Alzheimer's disease dementia) with low formal education (∼4 years). Measures of ADL included three complexity levels: Self-care, Instrumental-Domestic, and Instrumental-Complex. The specific cognitive functions were evaluated through a factorial strategy resulting in four cognitive domains: Executive Functions, Language/Semantic Memory, Episodic Memory, and Visuospatial Abilities. The Geriatric Depression Scale measured depressive symptoms. Multiple linear regression analysis showed executive functions and episodic memory as significant predictors of Instrumental-Domestic ADL, and executive functions, episodic memory and language/semantic memory as predictors of Instrumental-Complex ADL (22 and 28% of explained variance, respectively). Ordinal regression analysis showed the influence of specific cognitive functions and depressive symptoms on each one of the instrumental ADL. We observed a heterogeneous pattern of association with explained variance ranging from 22 to 38%. Different instrumental ADL had specific cognitive predictors and depressive symptoms were predictive of ADL involving social contact. Our results suggest a specific pattern of influence depending on the specific instrumental daily living activity.
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Objectives: To investigate the importance of the CDT compared to other commonly used tests, in the diagnosis of dementia in the elderly; (2) to evaluate the reliability and correlation between available CDT scoring scales from recent studies. Methods: A systematic search in the literature was conducted in September 2008 for studies comparing CDT scoring systems and comparing the CDT with neuropsychiatric batteries. Results: Twelve studies were selected for analyses. Seven of these studies compared CDT scoring scales while five compared the CDT against the CAMCOG and the MMSE. Eight studies found good correlation and reliability between the scales and the other tests. Conclusion: Despite the mixed results in these studies, the CDT appears to be a good screening test for dementia.