Escitalopram in the acute treatment of depressed patients aged 60 years or older.

OBJECTIVE: The present study examined the efficacy and tolerability of acute escitalopram treatment in depressed patients aged 60 years or older. METHODS: Patients aged > or =60 years with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition major depressive disorder were randomized to 12 weeks of double-blind, flexible-dose treatment with escitalopram (10-20 mg/day; N = 130) or placebo (N = 134). The prospectively defined primary efficacy end point was change from baseline to week 12 in Montgomery-Asberg Depression Rating Scale (MADRS) total score using the last observation carried forward approach. RESULTS: A total of 109 (81%) patients in the placebo group and 96 (74%) patients in the escitalopram group completed treatment. Mean age in both groups was approximately 68 years. Mean baseline MADRS scores were 28.4 and 29.4 for the placebo and escitalopram treatment groups, respectively. Escitalopram did not achieve statistical significance compared with placebo in change from baseline on the MADRS (least square mean difference: -1.34; last observation carried forward). Discontinuation rates resulting from adverse events were 6% for placebo and 11% for escitalopram. Treatment-emergent adverse events reported by >10% of patients in the escitalopram group were headache, nausea, diarrhea, and dry mouth. CONCLUSIONS: Escitalopram treatment was not significantly different from placebo treatment on the primary efficacy measure, change from baseline to week 12 in MADRS. In patients aged 60 years or older with major depression, acute escitalopram treatment appeared to be well tolerated.     

Lacunar infarcts in patients aged 85 years and older

OBJECTIVES: To compare the occurrence of lacunar infarcts in the very elderly ( > or = 85 years of age) and in patients below 85. MATERIAL AND METHODS: Data of 374 consecutive patients with lacunar infarcts were collected from a prospective hospital-based stroke registry in which 2000 patients are included. Distinctive clinical features of lacunar infarct in the very elderly were assessed by multiple logistic regression analysis. RESULTS: Lacunar infarcts were diagnosed in 39 (15%) of the 262 very elderly patients of our stroke registry. Lacunar infarcts in the very elderly accounted for 10.5% of all lacunes. There was no statistical difference in the occurrence of different lacunar syndromes between the very elderly patients and patients below 85. However, the very old group with lacunar infarct showed a significantly higher proportion of the female sex (56.4% vs 37.3%) and history of atrial fibrillation (28.2% vs 8.7%), chronic renal disease and pathologic condition and a significantly lower proportion of hypertension (61.5% vs 77.3%), diabetes (7.7%) vs 28.4%), ischemic heart disease, hypercholesterolemia, and absence of neurologic deficit at discharge from the hospital than patients below 85. After multivariate analysis only atrial fibrillation (OR = 3.77), female gender (OR =2.52), hypertension (OR = 0.35), and diabetes (OR = 0.16) were independent clinical factors for developing lacunar infarction in the very elderly. CONCLUSION: In the very elderly the higher occurrence of atrial fibrillation, the lower prevalence of hypertension and diabetes, and the greater focal neurological impairment suggest that the cardioembolic pathogenetic mechanisms may be more frequent than generally established for lacunar infarcts in stroke patients.     

Outcomes of 24 patients with subarachnoid hemorrhage aged 80 years or older in a single center

OBJECTIVE: In the developed countries, elderly population is rapidly increasing, but outcomes of elderly patients with subarachnoid hemorrhage (SAH) remain unclear. PATIENTS AND METHODS: We retrospectively reviewed the medical records of non-traumatic SAH patients aged 80 years or older, who were hospitalized in a single center between 2000 and 2005. RESULTS: There were 24 patients (80-92 years old and 83% female), representing 8.8% of all non-traumatic SAHs (n=272). Of those, six patients received an intervention (five clipping and one endovascular coiling) and the remaining 18 patients were managed conservatively. The patients who received an intervention were younger and had a better consciousness at presentation. Early mortality rate within 30 days after SAH was higher in the conservative group (61% [11/18] and 17% [1/6], p=0.155). At 6 months, mortality rate was significantly higher in the conservative group (83% [15/18] and 33% [2/6], p=0.038), and independence rate was higher in the intervention group (33% [2/6] and 0% [0/18], p=0.054). Logistic regression analysis showed that age and degree of consciousness on admission were significant predictor of outcome in 4 weeks, and that receiving intervention was significant predictor of outcome in 6 months. CONCLUSION: In elderly SAH patients with good clinical condition at presentation, an active intervention may improve the outcome.     

Conjugal loss and syndromal depression in a sample of elders aged 70 years or older.

OBJECTIVE: The goal of this study was to describe the association between conjugal loss and both syndromal depression and depressive symptoms in a prospective cohort study of people aged 70 years or older. METHOD: A measure of syndromal depression, the shortform Composite International Diagnostic Interview (CIDI), and a revised version of the Center for Epidemiologic Studies--Depression Scale (CES-D Scale) were administered to a group of 5,449 elders in a longitudinal cohort study. The authors compared the rates of syndromal depression (CIDI diagnosis) and depressive symptoms (six CES-D Scale symptoms) in married participants and those who lost spouses between the first and second waves of assessment. RESULTS: The rate of syndromal depression in the newly bereaved was nearly nine times as high as the rate for married individuals, and the rate of depressive symptoms was nearly four times as high. The percentage of the bereaved respondents who had scores above threshold on the revised CES-D Scale was higher for those interviewed up to 2 years after loss of a spouse than for married respondents. Age, sex, prior psychiatric history, and the expectedness of the death did not differ between depressed and nondepressed newly bereaved subjects. CONCLUSIONS: Recent bereavement is a significant risk factor for syndromal depression in the elderly. Some widows and widowers experienced high levels of depressive symptoms up to 2 years after the loss of their spouses. Neither demographic variables nor variables concerning the nature of the spouse's death predicted bereavement-related depression.     

Use of levetiracetam in a population of patients aged 65 years and older: a subset analysis of the KEEPER trial

Levetiracetam (Keppra) was evaluated in a subset of patients aged >/=65 years (n=78) enrolled in a large (n=1030) open-label, phase IV trial (the KEEPER trial). A 4-week dose adjustment was followed by a 12-week evaluation period. An overall median reduction in partial seizures of 80.1% (n=65) was observed. Overall, 76.9% of patients were >/=50% responders, 56.9% were >/=75% responders, and 40.0% were 100% responders. Levetiracetam was well tolerated, with 42.3% of patients reporting one or more adverse events. A total of 15 patients (19.2%) experienced an adverse event that led to discontinuation. Somnolence (n=13,16.7%) and dizziness (n=7,9.0%) were the most commonly reported adverse events. Despite the limitations of the open-label study design, these data provide information regarding the use of levetiracetam as add-on therapy for the treatment of partial-onset seizures in patients >/=65 years of age, including those requiring concomitant medications.     

Dementia with Lewy bodies according to the consensus criteria in a general population aged 75 years or older

OBJECTIVE: To estimate the prevalence of dementia with Lewy bodies (DLB) according to the consensus criteria in a general population aged 75 years or older. METHODS: The "Kuopio 75+ study" is a population based health survey focused on the clinical epidemiology of dementia and functional capacity among elderly subjects aged 75 years or older. On 1 January 1998, a random sample of 700 subjects was drawn from a total population born before 1 January 1923, living in the city of Kuopio, northeast Finland (n = 4518). The study subjects underwent a structured interview and clinical examination. RESULTS: 601 elderly subjects (86% of the random sample) were examined. A dementia disorder was diagnosed in 137-a prevalence of 22.8% (95% confidence interval 19.4% to 26.2%). The prevalence of DLB was 5.0% (3.2% to 6.7%), comprising 22% of all demented subjects. Probable DLB was diagnosed in 20 subjects (3.3% (1.9% to 4.8%)), and possible DLB in 10 (1.7% (0.6% to 2.7%)). The prevalence of Alzheimer's disease was 10.6% (47% of all demented subjects), of vascular dementia, 5.3% (23%), and of other types of dementing disorders, 1.8% (8%). CONCLUSIONS: In a general population aged 75 years and older, the prevalence of a disorder fulfilling the diagnostic criteria of DLB is half that of Alzheimer's disease and the same as for vascular dementia.     

Screening for undiagnosed parkinsonism in people aged 65 years and over in the community

We screened a random sample of 2449 people aged 65 years and over for undiagnosed parkinsonism, using a postal screening questionnaire followed by clinical neurological assessment. Amongst the 1556 (63.5%) patients who responded, four patients with previously undiagnosed parkinsonism were identified, suggesting a prevalence of 257 per 100,000 (95% CI 70, 658) in this age-group. Although only small, the numbers were sufficient to significantly increase the incidence of parkinsonism in an incidence study. Two simple screening questions achieved a high sensitivity for newly diagnosed parkinsonism of 95%, but a low specificity of 28%.     

Family relationships and morale among people 65 years of age and older.

The interrelationship of specific types of family relationship--marital and parent-child relations in particular--among older adults is examined. Findings suggest that caution must be exercised when generalizing about the importance of family relationships in the lives of older adults, and that future inquiries should focus on the qualitative aspects of family relations. Suggestions for professionals dealing with older people are offered.     

Cardiovascular risk factors in patients aged 85 or older with ischemic stroke

OBJECTIVES: To define a cardiovascular risk factor profile in very old patients with ischemic stroke. PATIENTS AND METHODS: Data from a prospective hospital-based stroke registry was collected. Demographic characteristics and cardiovascular risk factors in individuals aged 85 years or older with ischemic stroke (n=303) were compared with patients under 85 years (n=1537). RESULTS: The study population accounted for 16.5% of all cases of ischemic stroke. The mean (S.D.) age was 88.2 (2.8) years (70% women). Hypertension occurred in 44.9% of patients, atrial fibrillation in 42.6%, diabetes in 16.2%, and congestive heart failure in 15.5%. The most frequent stroke subtypes were cardioembolic (36%) and atherothrombotic (31.4%) infarction. Congestive heart failure (odds ratio [OR]=3.62), chronic renal disease (OR=2.54), female sex (OR=2.27), previous cerebrovascular disease (OR=1.71), and atrial fibrillation (OR=1.38) were significantly associated with ischemic stroke, whereas diabetes (OR=0.68), hypertension (OR=0.61), hyperlipidemia (OR=0.45), and heavy smoking (OR=0.21) occurred more frequently in patients under 85 years. CONCLUSION: Adequate treatment of potentially modifiable risk factors, including congestive heart failure, chronic renal disease, and atrial fibrillation may contribute to prevent ischemic stroke in very old people.     

Meningioma surgical outcomes and complications in patients aged 75 years and older

ObjectiveMeningioma incidence increases with age, yet limited data exist on how comorbidities impact complication rates in elderly patients undergoing meningioma resection. The objective of this study was to report surgical outcomes and identify risk factors for perioperative complications.MethodsWe performed a retrospective study of patients 75 years and older undergoing meningioma resection. Outcomes included survival and complications. Major complications were those requiring surgical intervention or causing permanent neurological deficit. Recursive partitioning, Kaplan-Meier survival, univariate and multi-variate (MVA) analyses were performed.ResultsFrom 1996 to 2014, 103 patients with a median age of 79 years (IQR 77–83 years) underwent cranial meningioma resection. Median follow-up was 5.8 years (IQR 1.7–8.7 years). Median actuarial survival was 10.5 years. Complications occurred in 32 patients (31.1%), and 13 patients (12.6%) had multiple complications. Major complications occurred in 16 patients (15.5%). Increasing age was not a significant predictor of any (p = 0.6408) or major complication (p = 0.8081). On univariate analysis, male sex, Charlson Comorbidity Index greater than 8, and cardiovascular comorbidities were significantly associated with major complications. On MVA only cardiovascular comorbidities (OR 3.94, 95% CI 1.05–14.76, p = 0.0238) were significantly associated with any complication. All patients with major complications had cardiovascular comorbidities, and on MVA male gender (OR 3.78, 95%CI 1.20–11.93, p = 0.0212) was associated with major complications.ConclusionsCardiovascular comorbidities and male gender are significant risk factors for complications after meningioma resection in patients aged 75 years and older. While there is morbidity associated with meningioma resection in this cohort, there is also excellent long-term survival.     

Significance of silent infarcts in acute ischemic stroke patients aged 80 years and older

BACKGROUND: The significance of silent infarcts (SIs) is unknown in very elderly patients with first-ever acute ischemic stroke. METHODS: Fifty patients aged 80 years and older with first-ever acute ischemic stroke were studied. The conventional risk factors for stroke, the scores of age-related white matter changes, and the findings on echocardiography were compared between patients with and without SIs. RESULTS: Thirty-eight patients (76%) had one or more SIs. The patients without SIs frequently had atrial fibrillation (50% vs. 13.2%, p = 0.014) or spontaneous echo contrast or thrombi on echocardiography (57.1% vs. 0%, p = 0.026) and showed lower scores on age-related white matter changes (0.5 +/- 0.67 vs. 1.13 +/- 0.58, p = 0.002) than did patients with SIs. There were no differences in other risk factors for stroke between the two groups. CONCLUSION: In patients aged 80 years and older, the absence of SIs with a first-ever acute ischemic stroke may suggest the presence of cardiac embolic sources or atrial fibrillation.     

Caregiver report of hallucinations and paranoid delusions in elders aged 70 or older

This study examined the demographic, medical, and psychiatric correlates of hallucinations and paranoid delusions reported by proxy informants for 822 elders aged 70 or older. This sample comprised people who were deemed unable to complete a direct interview in a large nationwide study of aging. Marital status, trouble with vision, and cognitive impairment were associated with report of both paranoid delusions and hallucinations. Depressive symptoms and stroke were associated with hallucinations only. These results suggest that inadequate external stimulation in the elderly leads to psychotic experiences.