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Objectives: Electroconvulsive therapy (ECT) administration rises in frequency with age, with older depressed adults often showing clinical features predictive of good response. Recent reviews suggest that older people experience few if any long-term cognitive adverse effects after contemporary ECT, despite their increased vulnerability to these. However, the broader clinical validity of research findings is not assured as most studies of ECT-related cognitive effects do not discuss cognitive test nonparticipants. This study examines whether cognitive test participants and nonparticipants are comparable., Methods: We recently completed a study of cognition in depressed patients 65 years and older treated with ECT. Only 35% of eligible patients completed neuropsychological testing at 2 time points, the remainder either refusing or unable to consent. To examine whether exclusion of most eligible patients from cognitive testing might have affected the clinical applicability of findings, we compared demographic and clinical characteristics of patients who participated with those who did not based on a subset of patients from our original study., Results: The 2 patient groups differed in several respects. Most notably, nonparticipants were significantly more likely to be involuntary patients; to refuse food and fluids; and to require treatment with a bitemporal or mixed electrode placement., Conclusions: Our findings suggest cognitive test nonparticipants to be more severely psychiatrically unwell than test participants. As their exclusion might bias results and confound understanding of this important ECT-related topic, special mention of participation rates and comparison of participants and nonparticipants is recommended to establish the clinical relevance of future study findings.

Background: The cognitive side-effects of ECT are minimized by individualized, supra-threshold dosing with brief pulse electrical stimuli. Unilateral ECT is associated with fewer cognitive sequelae but bilateral ECT is possibly more effective. Little is known of the relative effectiveness and tolerability of the two placements in the treatment of elderly, severely depressed inpatients., Methods: Patients of five public aged psychiatry services and a private psychiatric hospital who received right unilateral ECT (n=47) dosed on average at 3 times seizure threshold or bitemporal ECT (n=16) dosed at 1.5 times threshold completed an abbreviated Rey Auditory Verbal Learning Test, a visual memory test and a section of the Autobiographical Memory Inventory as close as possible to 24h after the first or second treatment and again after the fifth or sixth treatment. This design was intended to maximize recruitment of severely depressed patients with a limited ability to consent and cooperate with testing., Results: Only 35% of eligible patients completed both assessments, mostly due to refusal or lack of capacity to consent. Moderate dose unilateral and bilateral ECT produced equivalent improvements in mood. There was a tendency for scores on most cognitive tests to decline more with bilateral than unilateral ECT but these differences were statistically significant only for immediate verbal memory and autobiographical memory., Conclusions: Our findings suggest that bilateral ECT is no more effective as an antidepressant than moderately dosed unilateral ECT, at least on a short-term basis, and confers a slightly greater risk of cognitive impairment. This supports the rationale of prescribing unilateral ECT in the first instance in this vulnerable clinical population., Limitations: It proved impossible to recruit most ECT recipients, limiting the capacity to generalize findings to all aged patients. Reports concerning ECT should list recruitment rates to help set findings in context., (Copyright 2009 Elsevier B.V. All rights reserved.)

Objective: To review studies that examined the impact of electroconvulsive therapy (ECT) on cognitive functioning in depressed older people., Methods: Studies were systematically retrieved using PsychINFO and MEDLINE, with additional articles sourced from lists of references. Given our aged-care focus, study participants had a minimum mean age of 60 years, with no single participant younger than 50 years., Results: Twenty-seven studies met our criteria. Apart from evidence of interictal slowing of information processing speed, there were mixed results with regard to the impact of ECT on other cognitive domains. Factors contributing to this variability in results include the lack of discrimination between unilateral, bilateral, or mixed electrode placement; the inclusion of patients with dementia; the small sample sizes; and the use of tests insensitive to subtle cognitive changes., Conclusions: The effect of ECT in elderly recipients' cognition remains unclear, and further research with more critically selected methods is required. In the meantime, we recommend that clinicians regularly administer brief focused cognitive tests before, during, and after treatment to monitor progress.

Objectives: to compare the domiciliary service receipt of cognitively impaired and equally dependent physically impaired elderly women prior to the passing of the UK Community Care Act., Methods: secondary analysis of a population survey conducted in 1986 in the city of Cambridge. The analysis used data on 1585 women aged 75 and over living in the community. The effect of type of impairment on the receipt of domiciliary services (meals-on-wheels, home help and community nursing) is measured using a multivariate model which allows for adjustment for dependency level and other potential confounding factors., Results: the odds of an elderly woman getting help from any of the domiciliary services whilst not being significantly affected by cognitive impairment (odds ratio 0.7, 95% CI 0.5-1.2) are increased by physical impairment (odds ratio 1.8, 95% CI 1.2-2.5). Similar results were found for the home help service. The differences were exaggerated in the case of the community nursing service, whilst receipt of meals-on-wheels was similar for women of with all types of impairment., Conclusions: in the late 1980s, cognitively impaired elderly women received less help from the domiciliary services than equally dependent physically frail women who lived in similar household circumstances. The development of specialist services appropriate to the needs of cognitively impaired elderly people presents a challenge to community care policy, especially since this group are at high risk of institutionalization.

An increased apolipoprotein E (ApoE) type epsilon 4 allele frequency is associated with both sporadic and familial late-onset Alzheimer's disease (AD). The age of onset of disease in patients homozygous for the epsilon 4 allele appears to be decreased by approximately 15 years compared with E2/3 individuals. In order to assess the influence of this allele on both dementia and cognitive decline in the elderly we have determined the ApoE genotype of 150 individuals over the age of 75 years who have taken part in a longitudinal study. Homozygosity for the epsilon 4 allele was rare. Of the 2 homozygotes, 1 was severely demented but the other did not receive a clinical diagnosis of dementia. The latter individual did demonstrate marked cognitive decline over a 28-month period. There was a consistent association between the presence of an epsilon 4 allele and both the clinical diagnosis of dementia and cognitive decline. These findings confirm a genetic heterogeneity in late-onset sporadic AD and prompt caution in the use of ApoE genotype to predict an elderly individual's susceptibility to either dementia or cognitive decline.

We wished to test the hypothesis that elderly people with impaired cognitive function were heavier users of both outpatient and inpatient hospital services. In a retrospective cohort study, 144 elderly people aged 75-97 years (50 men and 94 women) identified from a prevalence survey of dementia were traced over an average period of 4 years. They were categorized into three groups: cognitively impaired, physically frail and physically healthy. Elderly people with impaired cognitive function had fewer contacts with outpatient services (p = 0.0003) but did not differ in inpatient service use from subjects with normal cognitive function. Cognitively impaired people who lived alone had longer hospital stays (p = 0.002) and a higher admission rate to geriatric wards (p = 0,009). Negative self-rated health was an important factor predicting more contacts for men with inpatient services and geriatric outpatient services (both p = 0.002). Use of surgical outpatient services was associated with use of surgical inpatient services by the physically healthy group only (p = 0.0003). After adjusting for age, sex and physical health, cognitively impaired subjects were nearly twice as likely to die within four years as the other two groups (RR = 1.89).

A sample of 1111 survivors from a population aged 75 years and over completed the Mini-Mental State Examination (MMSE) twice, separated by 28 months on average. There was a mean decline of 1.3 points in MMSE score. With increasing age, mean drop in score also increased. The proportion at each age identified as newly cognitively impaired according to any standard cut-point on MMSE rose markedly. Mean decline was greater in women than men even after adjustment for age. Cognitive change on the MMSE was approximately unimodally and normally distributed. This distribution was a marked contrast to the distribution of MMSE scores themselves, which was skewed due to truncation of scores at the maximum. The decline was not due to the inclusion of individuals with physical impairment. These findings indicate that cognitive decline, like dementia, becomes increasingly common with advancing age, and suggest that dementia may be regarded as one extreme of the continuum of cognitive decline.