27th Nordic Psychiatric Congress

ABSTRACTS: N - Nape

N - 1 Wednesday 13/8, 10:10-10:30
The association between age and depression in the general population: a multivariate examination

Eystein Stordal MD, Helse Nord-Trøndelag HF, Hospital Namsos, Department of Psychiatry, N-7800 Namsos, Norway. Arnstein Mykletun MA, Alv A. Dahl MD, PhD.

Eystein.stordal@hnt.no

Background: In a large general population study we found a close to linear rise with age in the mean score and prevalence of self-reported symptoms of depression.

Aims: To examine if this linear relation prevailed when controlled for multiple variables, and to examine what factors that eventually explained the association.

Method: Among individuals aged 20-89 years living in Nord-Trøndelag County of Norway, 60869 filled in valid ratings of the Hospital Anxiety and Depression Scale (HADS) as well as many other variables. Covariates were grouped into a multivariate model with six blocks. Logistic regression was used to model the blocks and variables with caseness of depression as the dependent variable.

Results: The model explains a considerable part of the age-related pattern on depression. The pattern became less distinct in the age groups above 50 years. Variables within the blocks of somatic diagnoses and symptoms, as well as impairment, had most explanatory power. Four blocks reduce the prevalence of depression significantly: Impairment, sociodemographics, somatic diagnosis and somatic symptoms. Eight single variables reduce the age-effect: Education, impairment caused by movement, hearing, vision and physical disease, physical activity, muscle skeletal disorders, and muscle skeletal symptoms.

Conclusions: Due to our large sample we were able to control for more relevant variables than earlier studies. In contrast to most other studies, we found that an age-related increase of the prevalence of depression persisted after control for multiple variables.



N - 2 Wednesday 13/8, 10:30-10:50
Epidemiology of old age in Iceland


Hallgrímur Magnússon, dr med, Head of Department, Dept. of Psychiatry of Old Age, Ullevål University Hospital, Slottsbergen 35, 1385 Asker, Norway

hallgrimur@oslo.online.no

Introduction: In Iceland a longitudinal epidemiological study of a birth cohort has been carried out. The study covers almost the whole lifespan of every Icelander born in three consecutive years. The study based its case finding and diagnosis on extensive interviews with the general practitioners in the country and on thorough review of medical records. This strategy was timely when it first appeared but in the last phase of the study it was supplemented with interviews of the subjects themselves using the Geriatric Mental State Schedule.

Results: The prevalence of depression in Iceland was 7,9% and 8,7% at the age of 81 and 87 years respectively. Compared to similar studies in Europe, Iceland has the lowest prevalence. Iceland also has very low suicidal rate in old age compared to other countries. Pattern of depressive symptoms in the general population in Iceland differed considerably from similar data in other countries in Europe.

The prevalence of dementia in Iceland was 7,8 and 15,1 at the age of 81 and 87 years respectively. Several recent studies on the incidence rate of dementia show results similar to the Icelandic study.


N - 3 Wednesday 13/8, 11:10-11:30
Psychotropic use in the homedwelling elderly


Sirpa Hartikainen, Clinical Lecturer, Kuopio University, Division of Geriatrics, Department of Public Health and General Practise, Finland

sirpa.hartikainen@uku.fi

Psychotropic use is common and becoming even more common among the elderly in Finland. This use includes lots of adverse effects, especially falls and cognition. Risks of interactions grow when using with several other medicines.

The Kuopio 75+ Study is a population based health survey focused on epidemiology of medicine use and functional capacity among the elderly subjects aged 75 years or older. A random sample of 700 subjects was drawn from a total population aged at least 75 years and living in the city of Kuopio on January 1, 1998 (n=4518). A structured clinical examination and interview were carried out for 601 subjects (86% out of random sample) by a geriatrician and a trained nurse. Those living in institutions (n=78) were excluded; thus, 523 persons were subjects in this study.

At least one psychotropic medicine was used by 37% of the elderly and 12% were using at least two psychotropics concomitantly. Those using psychiatric medication were older, more often widowed, and living alone than non-users. The probability of psychotropic use increased linearly with age for anxiolytics/ hypnotics and for antipsychotics, but not for antidepressants. Anxiolytics and hypnotics were most commonly prescribed psychotropic medicine (30%) and one-tenth was using antidepressant (11%) or antipsychotic medicine (9%).

The demented person more often uses all kinds of psychotropic medicines than non-demented. One of four demented elderly compared to one in ten non-demented used at least two psychotropics. The demented elderly used antipsychotics six times more often than the non-demented and tended to use antidepressants more commonly as well.

Among the non-demented elderly, one out of every two antipsychotics (N=31) users was suffering from depression according to DSM IV criteria. However, at the same time most non-demented depressed persons (N=79, 68%) were not receiving any antidepressant medication.

Conclusion: Prescription practice that most commonly gives psychotropic medication to the oldest and most vulnerable ones includes high risks of adverse effects and interactions. It seems that the threshold to prescribe antipsychotics to the elderly is low. The depression in the elderly seems to be underdiagnosed, undertreated or mistreated in the non-demented elderly.



N - 4 Wednesday 13/8, 11:30-11:50
Evidence-based treatment of dementia. State of the art


Carsten Emil Olsen1, MD, NAPE, Poulsen2 HD, MD, PhD, Lublin2 HKF, MD, DrMedSC.

1Hvidovre University Hospital, Copenhagen, Denmark, 2Rigshospitalet, Copenhagen Denmark

Background: Drug therapy of dementia in the elderly is today possible. Furthermore, behavioural and psychological symptoms of dementia (BPSD) can be treated with anti-psychotics and possibly with anti-dementia drugs. Due to an increase in the number of elderly, evidence-based treatment of dementia is required.

Material and methods: Evidence-based (level 1 b) review of peer reviewed, double-blind, randomized trials of donepezil, galantamine, rivastigmine and memantine up to December 2002. A total of 26 studies were included.

Results: Donepezil, galantamine, rivastigmin, and possibly also memantine improve the cognition and the global level of functioning in mild to moderate Alzheimer (AZ). Most evidence is present concerning galantamine and donepezil. Rivastigmine is the only drug documented to be effective in Lewy body dementia. Some evidence exists regarding galantamine, and perhaps donepezil, in vascular dementia. No solid documentation exists for the treatment of severe dementia.

Conclusion: Elderly with possible dementia should be medically examined and offered anti-dementia drugs. Today's indication for anti-dementia drugs only includes Alzheimer's disease, and should be considered to be expanded.



N - 5 Wednesday 13/8, 11:50-12:00
Dementia and ageing. An epidemiological study of the detection, preclinical phase, course and prognosis of dementia at age 85 to 88

Ólafur Þór Ævarsson, Institute of Clinical Neuroscience, Department of Psychiatry, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden

forvarnir@mmedia.is

A population in Gothenburg was followed from age 85 (N=494) to 88 (N=248). Methods included a neuropsychiatric and physical examination, key-informant interview, MMSE, and CT-scan. Medical records and death certificates were studied. I. The prevalence of dementia increased in women (31% to 46%) but not in men (27% to 25%). Proportion of vascular dementia was 47% at age 85 and 54% at 88, despite a higher mortality in vascular dementia. II. The incidence of dementia was 90.1/1000/year (61.3 men; 102.7 women; p=0.085). The incidence of Alzheimer's disease was 36.3/1000/year, vascular dementia 39.0/1000/year (p=1.000) and other dementias 9.1/1000/year. III. In the preclinical phase, both Alzheimer's disease and vascular dementia were preceded not only by cognitive impairments, but psychiatric, behavioral, and subcortical signs as well. IV. At the age of 85, the non-demented subjects had a mean score of 27.7 on MMSE, and demented 14.5 (p<0.001). More than half of those with mild dementia scored above the cut-off score 23/24. Of the non-demented, 75% scoring below 24 and 37% of those scoring 24 to 25 became demented during the follow-up. Subjects not developing dementia had a mean decline in MMSE-score of 0.6/year, while those who became demented declined by 2.3/year. Correlation was found between MMSE scores and education both in non-demented and demented. V. Among 20 mental and physical disorders studied, dementia was the most important predictor of mortality, predicting 31% of all deaths in men and 50% of all deaths in women, calculated by Population Attributable Risk (PAR). Life expectancy decreased with dementia severity. Survival in women with mild Alzheimer's disease was similar to that of non-demented women.



N - 6 Wednesday 13/8, 12:00-12:10
Dementia and mental disorders among elderly in primary care


María Ólafsdóttir, NAPE, MD, PhD, General Practitioner, Ass. Professor University of Iceland, The Primary Care, Reykjavík, Mávahrauni 1, 220 Hafnarfirði, Iceland. Skoog I, Marcusson J.

maria.olafsdottir@simnet.is

Aims: In order to investigate how elderly patients with dementia and mental disorders were managed in primary care, the prevalence of the diseases and detection was investigated.

Design: Patients aged 70 years and older visiting a primary care centre (PCC) in Linköping (N=1225) were examined with a Mini Mental Status Examination (MMSE). In a sub-sample (N=350) a comprehensive neuro-psychiatric examination and an interview with a close informant were conducted. All medical records (N=350) in the PCC were reviewed regarding diagnoses, medication and the number of visits to the centre. Dementia and mental disorders were diagnosed according to DSM-III-R.

Results: The prevalence of dementia and mental disorder according to the psychiatric interview was 33% (16% dementia, 17% mental disorders). The frequency of psychiatric symptoms among those with no mental disorder was up to 66%. Dementia was detected in 25% of cases, depression in 12% of cases and anxiety in 30% of cases.

Conclusions: The prevalence of dementia and mental disorders in an elderly PCC population is high. As the major problem in the management of dementia and mental disorder has been under detection, some screening tool for cognitive function in this group is recommended and the formation of an effective network, to manage the continuing care of patients.



N - 7 Wednesday 13/8, 14:00-15:30
Psychiatric epidemiology of old age


Ingmar Skoog Institute of Clinical Neuroscience, Department of Psychiatry, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden

Dementia and other mental disorders are examined in representative samples followed longitudinally in Gothenburg, Sweden; The H70-study started 1971, the Women's Health Study started 1968, the 95+-study started 1996. Completed suicides in individuals above age 70 are also studied. Dementia are the most important predictor of death and institutionalization in old age. Vascular factors (infarcts, white matter lesions, hypertension), childhood factors and female sex after age 90 are related to risk of Alzheimer's disease. Life time prevalence of depression was 45% in women and 23% in men. The prevalence of depression was 9% both at age 70 and 95. The incidence of first-onset depression increased from age 70 to age 85. Female sex and neuroticism increased the incidence of depression. The proportion of 70-year-old depressed who were treated with antidepressants increased from 10% in 1971 to 56% in 2000. Current depression was related to poor performance on cognitive testing, but not to organic brain changes on brain imaging. Psychotic symptoms were found in 10% of non-demented 85-year-olds, and were related to cardiovascular disorders, increased mortality and increased incidence of dementia. However, only a minority of those with psychotic symptoms developed dementia during follow-up. Suicide after age 70 was strongly associated with depression, and the majority were diagnosed and treated for depression within 6 months before the suicide. Life weariness and other suicidal thoughts were rare in the mentally healthy elderly, and were related to an increased mortality in women independently from comorbid physical disorders.



N - 8 Wednesday 13/8, 15:50-17:00
A population study of dementia after age 95


Anne Börjesson Hanson, MD, Psychiatry Section, Inst. of Clinical Neuroscience, Sahlgrenska University Hospital, Blå str 15, SU/Sahlgrenska, SE-413 45 GÖTEBORG, Sweden. Þorsteinn Gíslason, Eva Edin, Ingmar Skoog

anne.borjesson@neuro.gu.se

Objective: To study dementia in extreme old age.

Design: Longitudinal population study.

Materials and Methods: The 95+ study includes more than 700 comprehensive neuropsychiatric examinations of individuals from age 95 to 101 years. Dementia and its severity were diagnosed according to the DSM-III-R criteria, Alzheimer's disease (AD) according to the NINCDS-ADRDA criteria and vascular dementia (VaD) according to criteria proposed by Erkinjuntti.

Results: The prevalence of dementia was 51% at age 95 (N=338) and increased to 58% at age 97 (N=167). At age 95, the prevalence was 36% for AD, 15% for VaD, including mixed dementia. The incidence of dementia between age 95 and 97 was 173/1000 person years at risk. The proportion of mild dementia was 5%. Institutionalization rate was 26% for non-demented and 85% for demented at age 95 and increased to 30% for non-demented and 95% for demented at age 97.

Conclusions: The prevalence of dementia continues to increase after age 95. The incidence rate of dementia was higher between age 95-97 than between age 85-88 (90/1000 person years at risk). In line with several other studies the proportion of mild dementia decreased from 28% at age 85, 19% at age 88 to 5% at age 95. One reason may be that DSM-III-R severity criteria are based on the need for assistance in daily living. Therefore, the higher frequency of physical co-morbidity in the extremely old will give a lower proportion of mild dementia. When a physically impaired individual reaches the threshold for dementia, the degree of severity will thus be higher than for a physically unaffected individual. Another explanation could be that the brains of extremely old individuals may be more fragile. When this is superimposed by Alzheimer encephalopathy the decline into more severe dementia may be faster than in younger groups.



N - 9 Wednesday 13/8, 15:50-17:00
Preclinical stages of Alzheimer's disease and vascular dementia: A three year follow-up of 85 years olds - the H 70 study

Simona Sacuiu1, Magnus Sjögren1, Boo Johansson2, Ingmar Skoog1

1Institute of Clinical Neuroscience, Department of Psychiatry, Sahlgrenska University Hospital and 2Institute of Psychology, Gothenburg University, Gothenburg, Sweden

Background: Most studies on cognition and early dementia use neuropsychiatric examination or psychometric tests. The importance of self-reports and key-informant interviews in the early stages of dementia is controversial. Moreover, memory problems are often mentioned as predictor of dementia, but are they sufficient to predict dementia?

Aim: Evaluate the predictive value of four sources of information (self-report, key-informant report, neuropsychiatric examination, standard psychometric tests) on cognition (memory, language, visuospatial, executive function) in non-demented 85 year-olds that developed dementia within three years.

Method: The cognitive performance was recorded in a representative population sample of non-demented 85 year-olds (N=313) from Gothenburg, Sweden that was thereafter followed for three years for incident dementia. We evaluated the contribution of different clinical sources and cognitive domains at the prediction of dementia using logistic regression analyses with total dementia (N=58), vascular dementia (N=27), Alzheimer's disease (N=24) as outcomes.

Results: The neuropsychiatric examination independently predicted AD, whereas the psychometric tests independently predicted VaD. VaD and AD were independently predicted by poor memory (all sources, except self-reported memory predicted AD, but not VaD) and language (neuropsychiatric examination, psychometric tests).

Conclusion: Multiple sources of information covering multiple cognitive domains are necessary to predict the development of AD or VaD.



N - 10 Wednesday 13/8, 15:50-17:00
Sexual activity and attitudes to sex in 70-year-olds


Beckman N, Institute of Clinical Neuroscience, Section of Psychiatry, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden. Skoog I

nils.beckman@neuro.gu.se

Objective: To study birth cohort differences in sexual attitudes and prevalence of sexual activity in 70-year old non-demented men and women.

Methods: Representative samples of 70-year olds were examined in 1971-72 (cohort 1, N=361), 1976-77 (cohort 2, N=386), 1992-93 (cohort 3, N=285 women) and 2000-01 (cohort 4, N=492). The examinations were identical at each study year. The questions on sexuality were part of a psychiatric interview.

Results: The attitude to sexual activity among married 70-year-olds was positive in 77% in cohort 1, 83% in cohort 2, 97% in cohort 3 and 95% in cohort 4. The prevalence of sexually active 70-year-olds among married men was 52% in cohort 1, 53% in cohort 2 and 69% in cohort 4, and among married women 38% in cohort 1, 37% in cohort 2, 52% in cohort 3 and 59% in cohort 4.

Conclusion: The study suggests that attitudes to sexual activity in 70-year-olds are more positive today than 30 years ago. In accordance to this, the proportion of sexually active 70-year-olds has increased in both sexes.



N - 11 Wednesday 13/8, 15:50-17:00
Pain experience in Alzheimer's disease: Nurses' assessment and patients' own evaluation

Erik JA Scherder, Prof. Dr., Department of Clinical Neuropsychology, Van der Boechorststraat 1, 1081 BT Amsterdam, The Netherlands. Slaets, JB Deijen.

EJA.Scherder@psy.vu.nl

Background:
In previous studies caregivers over- or underestimated the pain of cognitively impaired nursing home residents. So far within this line of research, no attempt has been made to differentiate between the various types of dementia. It has been observed, however, that within Alzheimer's Disease (AD) subgroups of patients may experience less pain than non-demented elderly whereas some patients with vascular dementia (VaD) might perceive more pain than elderly without dementia. It is possible that patients with e.g. VaD are better able to indicate that they are in pain than patients with AD. Consequently, studies on nurses' assessment of patients' pain should focus on a specific type of dementia.

Aims: The primary goal of the present study was to examine the level of agreement between the pain perception of the nursing assistants (NAs) and that of nursing home residents, e.g. elderly without dementia and patients with AD.

Method: Forty nursing home residents with arthrosis and/or osteoporosis (20 with AD, 20 non-demented) and their personal NAs participated in a cross-sectional case-control study. Pain experience of the subjects and the NAs was assessed with the Coloured Analogue Scale (CAS), the Faces Pain Scale (FPS) and the Checklist for Nonverbal Pain Indicators (CNPI).

Results: The absolute difference in pain evaluation between the nurses and the non- demented elderly was significantly smaller than the difference in pain evaluation between the nurses and the AD patients, both with respect to pain intensity and pain affect. More specifically, the NAs overestimated the AD patients' pain.

Conclusion: The present results suggest that it was difficult for the NAs to estimate the AD patients' extent of suffering from pain. Future research is needed to establish whether such a discrepancy is also observed in patients with other types of dementia, e.g. VaD.

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