Depression

in Dementia

of the Alzheimer

and in Multi-Infarct

Peter

Fischer,

M.D.,

Ph.D.,

Margarete

Simanyi,

The authors used the Hamilton Rating Scale for Depression and a rating of depressed mood to investigate the prevalence of depression in 55 patients with Alzheimer’s disease, 3 7 patients with multi-infarct dementia, and 30 nondemented comparison subjects. The prevalence of depressed mood depended on the severity of dementia as measured by the Mini-Mental State examination and was significantly lower among patients in more severe stages of Alzheimer’s disease but not among patients with severe multi-infarct dementia. (Am J Psychiatry 1990; 147:1484-1487)

D

ementia of the Alzheimen’s type and multi-infarct dementia account for about 90% of dementias in geriatric cohorts, as demonstrated by neuropathological examination (1, 2). Estimates of depression range from 0% to 87% (3-8) in Alzheimer’s disease and from 19% to 27% in multi-infarct dementia (4, 5). Depressive symptoms burden the patients and their caregivers and may be treated with antidepressant drugs (5, 6, 9). Untreated symptoms of depression may be one important factor in the decision to institutionalize a demented patient. Notwithstanding the importance of depression in dementing disorders, to our knowledge no study has directly compared depression in Alzheimer’s disease with that in multi-infarct dementia in relation to severity of dementia. Depression in demented patients can either be defined as depressive disorder (i.e., DSM-III-R major affective disorder) on can be described at the level of depressive symptoms. Depressive symptoms can be roughly classified into affective (depressed mood), cognitive (hopelessness, helplessness, worthlessness, memory complaints), somatic (appetite, sleep, libido), and

Received

Dec.

12, 1989;

revision

received

April

3, 1990;

accepted

April 30, 1990. From the Neurological Department, Geriatric Hospital Vienna-Lainz, Vienna, Austria. Address reprint requests to Dr. Fischer, Neurologisches Institut der Universit#{228}t Wien, Schwarz-

spanierstrasse 17, A-1090 Wien, Austria. Supported in part by the L. Boltzmann Institute of Aging Research, Working Group on Alzheimer-Dementia-Research, and by a grant from the Austrian Academy of Sciences, Institute of Brain Research. The

authors

patients Copyright

1484

and

thank

Prof.

Drs.

A. Marterer

M. Streifler

© 1990

American

and

G.

Gatterer

for his comments. Psychiatric

Association.

for

testing

Type

Dementia

M.D.,

Ph.D.,

and

Walter

Danielczyk,

M.D.

psychomotor categories. Somatic and psychomotor symptoms are particularly common in old age without coexisting depressive disorder and are therefore nonspecific (10). Cognitive symptoms in demented patients are usually not attributed to depression. Affective symptoms are therefore the hallmark of depression in the demented elderly (3, 1 1). For that reason, in addition to rating depression by the “gold standard,” the Hamilton Rating Scale for Depression (12), which might be a sum scone of depressive symptoms of heterogeneous etiology in the demented elderly (13-15), we also investigated depressive affect, rated independently from the Hamilton depression scale. We tried to answer the question of whether depression depends on severity of dementia in Alzheimer’s disease and multi-infarct dementia, respectively.

METHOD The patients, 55 with Alzheimer’s disease and 37 with multi-infarct dementia, were inpatients of the neurological department of a geriatric hospital. They took pant in a prospective, longitudinal investigation of dementia in the elderly (16) and gave their consent to participate in our investigation after the nature of the procedure had been fully explained. Dementia was diagnosed according to DSM-III-R. Grading of severity of dementia was carried out by using the Mini-Mental State examination (17). According to the criteria of Folstein (18), only patients with Mini-Mental State scones of less than 24 were considered demented. Mild dementia was defined by Mini-Mental State scores ranging from 16 to 23; modenate dementia, by scores from 6 to 15; and severe dementia, by scores less than 6 (16). In the multi-infarct group 21 patients had mild dementia, 12 had moderate dementia, and four had severe dementia; in the Alzheimer’s disease group the numbers were 23, 13, and 19, respectively. All Alzheimem’s disease and multi-infarct dementia patients had been selected to fit the diagnostic criteria of DSM-III-R. Alzheimer’s disease patients also fulfilled the criteria for probable dementia of Alzheimen’s type of the Work Group of the National Institute of Neurological and Communicative Disorders and

Am

J Psychiatry

147:1

1, November

1990

FISCHER,

TABLE

1. Characteristics

of 37 Patients

With Multi-Infarct

Dementia,

55 Patients

With Alzheimer’s

SIMANYL,

Disease,

AND

DANIELCZYK

and 30 Nondemented

Com-

parison Subjects Mini-

Mental

A ge (years) Group

Women

Multi-infarct Alzheimer’s

dementia disease

Comparison aSignificant bSignificant cSignificant

Men

among among among

Range

Mean

SD

Range

Mean

SD

Range

0-23

10.3

4.3 5.8 1.7

3-19 2-27 0-7

3.7 4.1 1.5

1.3 1.7 0.9

1-7 1-7 1-5

76.6

7.0 8.8

59-85

14.6

6.5

58-93

11.5

9.1

78.2

4.5

69-87

28.6

1.0

(F=SS.32, df=2, (Kruskal-Wallis (Kruskal-Wallis

119, pO.0000). rank ANOVA; rank ANOVA;

Stroke and the Alzheimer’s Disease and Related Disorders Association (19). Diagnosis was based on a complete medical and neuropsychiatric examination including history, physical examination, ECG, EEG, CT of the brain, investigation of the ocular fundi, blood count, biochemistry (electrolytes, liver and kidney function, vitamin B12, folic acid), thyroid function, and serological tests for syphilis and AIDS. The Hamilton Rating Scale for Depression (12) was scored by an independent rater (M.S.), who was blind to symptom rating. Depressed mood was rated on a 7-point scale taken from the Sandoz Clinical Assessment-Geniatric (20) (1 =not present, 2=very mild, 3= mild, 4 = mild to moderate, S = moderate, 6 moderately severe, and 7=severe). The item description was, “Dejected, despondent, helpless, hopeless, preoccupation with defeat or neglect by family or friends, hypochondriacal concerns, functional somatic complaints, early waking. and behavior.”

Rate on patient’s statements, attitude This item was rated by the physician in agreement with the patient’s nurse. No patient meceived antidepressants at the time of the investigation on for 2 weeks previously. Thirty comparison subjects, from a home for the aged in the same district of Vienna as the geriatric hospital, volunteered for the study. Residents in this home were comparable to our chronic care inpatients with regard to education (years in school), socioeconomic status (income per month), gender, and age. They were clinically not demented and scored higher than 26 on the Mini-Mental State. Statistical analysis was performed at the computer center of the University of Vienna with the Statistical Package for the Social Sciences. Parametric procedures were used only with the dependent variables of age and Mini-Mental State score and included Student’s t test and one-way analysis of variance (ANOVA). Depression ratings were evaluated by nonparametmic procedunes: Mann-Whitney U test (for samples of more than 30 cases, U was transformed into a normally distributed Z statistic), Kruskal-Wallis one-way rank ANOVA (computes H statistic, which has approximately a chi-square distribution), and rank-order conrelation coefficient (Spearman’s rho). The level of significance was 0.05 (two-tailed).

Am

J Psychiatry

147:1

1, November

Mood

Scor?

SD

79.4 groups groups groups

Scale

Mean

7 2

Depressed

Scoret’

Range

9

three three three

Depres-

sion Scale

SD

28

the the the

Hamilton

Mean

48 28

difference difference difference

State

Scorea

1990

0-23 27-30

260.S8, 246.76,

12.4 2.4 df2, df”2,

pO.0000). p”O.OOOO).

RESULTS Characteristics

of patients

and

comparison

subjects

are shown in table 1. Multi-infarct dementia patients were slightly younger than Alzheimer’s disease patients.

According to the Mini-Mental State, dementia more severe in patients with Alzheimer’s disease than in patients with multi-infarct dementia (t=1.81, df=91, n.s.); we investigated only four severely demented patients with multi-infarct dementia as opposed to 19 severely demented Alzheimer’s disease patients. The mean Hamilton depression score was higher for patients with Alzheimer’s disease than for patients with multi-infarct dementia, but this difference did not reach significance (Z=-1.S1, MannWhitney U test). Nondemented comparison subjects had significantly lower scores on the Hamilton scale than the two other groups. Mean±SD Hamilton scores did not differ significantly among the various stages of multi-infarct dementia (10.5±4.0 for mild, 9.9± 5.3 for moderate, and 10.5±3.0 for severe dementia)

was slightly

(X2=0.14, ANOVA).

df=2, n.s., Kruskal-Wallis one-way rank The mean Hamilton scores were comparable in mild and moderate Alzheimer’s disease (13.1 ± 6.5 and 14.3±5.2), but the mean score was significantly lower in severe Alzheimer’s disease (9.9± 3.9) (2=6.06, df=2, p