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Table 2 Characteristics of included reviews and summary of findings - general older population

From: Systematic reviews on behavioural and psychological symptoms in the older or demented population

First author Search date BPS Popu-lation N reviewed Summary of results Meta-analysis Recommendations future research Reported limitations Quality
Prevalence and co-occurrence
Seitz [23] See 1A Mar 2009 BPS
Dep
Anx
Care home 35 Prevalence dep symptoms in long term care: 29% (14 to 82%) - - Developing countries
- Multinational studies
- Collaboration across centres
- Adoption of standard survey methods
- Effective and safe interventions
Original studies
- Small sample size
- Conducted in developed countries
- Included relatively few long term care facilities
- Many studies conducted several years ago
3
Luppa [28] May 2010 Dep Older (60+) 24 Prevalence of dep disorders ranged from 4.5 to 37.4%. Pooled prevalence: 17.1% (95% CI 9.7 to 26.1) Pooled prev major dep: 7.2% (95%CI 4.4 to 10.6) Dep disorders: 17.1 (9.7 to 26.1) - Large scale
- Population-based
- Prospective studies
- Also covering oldest age segments
- Comorbidity, cognition and function
- Suitable depression diagnostics
Original studies
- Methodological differences in study design, sampling structure and study quality
5
Chen [20] Jun 1997 Dep Older (60+) 10 Prevalence dep mood: 14.8 (14.2 to 15.6%), higher in rural communities Prev dep mood: 14.8% (14.2 to 15.6) - Similar methodology
- Culture-specific validated instruments
- Risk factors and understanding dep
Original studies
- Much variation
- Cultural acceptability of instruments
4
Beekman [29] 1996 Dep Older, community dwelling (55+) 34 The reported prevalence rates vary enormously (0.4 to 35%). Minor dep: 9.8% (8.3 to 14.3) Clinical dep symptoms: 13.5% (2.8 to 35%) - - Focus on those most at risk and in adverse socio-economic conditions
- Improving comparability of the data
Original studies
- Methodological differences
- Bias translating instruments
Review
- Formal meta-analysis was not considered justified
3
Meeks [30] Jan 2010 Dep Older (55+) 153 Dep was generally at least two to three times more prevalent than major dep. Prevalence lower in community settings (9.8%, 4.0 to 22.9) than primary care (15.1 to 35.9%) and LTC (4.0 to 30.5%). - - Incidence
- Prevalence
- Various clinical settings,
- Diverse geographical areas
- Cultural/socioeconomic groups
- Neurobiology
- Treatment
- Terminology of depression
- Associations with psychopathology
Review
- Could not conduct a meta-analysis due to data heterogeneity
- Review did not include data on early or mild adulthood subthreshold depression, limiting extrapolation of findings to other age groups
2
Djernes [31] Sep 2004 Dep Older (65+) 122 Prevalence clinical relevant depressive symptoms: 7.2 to 49% - - Target risk factors, improvement of prevention and treatment of chronic somatic and mental illnesses, adequate social support, prevention social isolation
- Education and information dep in elderly
- Comparability of methodology
- Focus on nursing home residence
Original studies
- Methodological differences
- Rates of participation; depressed elderly may be particularly prone to refuse research invitations
- Subjective variations in the assessment of the presence or absence of a diagnostic criterion
- Differences between instruments
2
Alwahhabi [32] 2001 Anx Older (55+) 119   - See disease outcome See disease outcome 1
Course and progression
Huang [35] Aug 2007 Dep Older (55+) 17 Non-dementia cognitive impairment vs without: incidence dep: OR = 1.5, 95% CI 0.9 to 2.5 prevalence dep: RR = 1.1, 95% CI 0.6 to 2.0. Dem vs. no dem: incidence OR = 1.8, 85% CI 1.2 to 2.9, prevalence RR = 3.9, 95% CI 1.9 to 8.0 See summary of results - Risk for cognitive impairment for depression Review
- No conclusion if dep was risk factor for dem
- No hand-search of journals and no attempt to identify unpublished studies. English language only
- Heterogeneity among included studies
- Confounding comorbidity other psychiatric disorders
- Data only gathered until august 2007
- Only four longitudinal studies included
5
Meeks [30] Jan 2010 Dep Older (55+) 153 8 to 10% of subthreshold dep developed major dep per year. Median remission rate to non-dep status 27% after > 1 year. - - Longitudinal course See prevalence 2
Jorm [33, 36, 37] End 2000 Dep Dem/Older 11, 15, 2 1991: history of dep (late onset cases) associated with AD (late onset). 2000: Dep increased risk of dem in case control, 95% CI 1.2 to 3.5 and prospective studies, 95% CI 1.1 to 3.2.; 2001: Update 2000: case control studies: RR = 2.0, 95% CI 1.2 to 3.5, prospective studies 1.9, 95% CI 1.1 to 3.2 Too many results 1991:
- Prospective studies
- History of psychiatric disorders other than dep and psychiatric treatments
2000/2001:
- Large sample size
- Mechanisms association dep and dem
Review
1991
- The pooled analyses cover only a small number of exposures from the domain of psychiatric history
0
Ohayon [38] 2003 Sle Adult ("healthy or normal") 65 Total sleep time, sleep efficiency, percentage of slow-wave sleep, percentage of REM sleep and REM latency all significantly decreased with age. Sleep latency, waking after sleep, waking after sleep duration and the percentage of stage 1 and 2 sleep increase with age, but only sleep efficiency continued to significantly decrease after 60 yr. Age - sleep: TST: r = -0.76 P < 0.0001 Sleep efficiency: r = -0.82, %SWS: r = -0.56% REM: r = 0.16 Sleep latency: r = 0.16% stage 1 sleep: r = 0.16% stage 2 sleep: r = 0.34 WASO: r = 0.75 All P < 0.0001 - Strict screening methods
- Effect of race
- Take into account subjects' habitual sleep schedules as well as whether PSG recording occurs on weekday or weekend night
Original studies
- No information given in relation with the presence or absence of sex differences, no information about race composition
- Several studies did not include middle-aged subjects
Review
- Limited to peer-reviewed studies
3
Floyd [39] 2002 Sle Adult ("healthy or normal") 244 Age and REM%: essentially linear, decreasing 0.6% per decade but ceased during mid-70s followed by small increase 75 to 85 Age - REM%: r = -0.17 - REM sleep in women
- More data in old-old population
Review
- Studies did not screen for psychoactive substance use, dep and sleep apnea, few studies of women
- Univariate approach
- Publication bias
2
Floyd [40] 1996 Sle Adult 41 Night-time sleep amount and the ability to initiate sleep decreased with age. Larger age-related changes when sleep variables were measured by polysomnography rather than self-report. Age - sleep, effect size: Sleep latency: 0.19 (0.14 to 0.24) WASO frequency: 0.38 (0.34 to 0.42) WASO duration: 0.74 (0.71 to -0.77) Night time sleep amount: -0.33 (-0.37 to -0.28) - Controlling for health moderators (carefully assessed for levels of depression, sleep apnea and use of psychoactive substances)
- Study women
Original studies
- Inclusion or exclusion of certain covariates may have influenced which predictors emerged as significant
- Very few of the studies examined the effects of collinearity, moderation or mediation among critical predictor variables
- Range of quality scores
Review
- Heterogeneity made the estimation of pooled effects impractical
1
Biological
Huang [43] Aug 2007 Dep Older (55+) 28 Significant OR and RR for increased dep in old age: stroke, loss of hearing, loss of vision, cardiac disease or chronic lung disease had a. Significant OR but un-significant RR: arthritis, hypertension and diabetes. Both OR and RR not significant: gastro-intestinal disease Too many results   Review
- Not hand-search journals, not identify unpublished studies, three databases, only English language
- Risk factors dep might be differently related to the onset, chronicity and recurrence but not differentiated
- Recent life event not taken into account
- Heterogeneity in results
5
Huang [44] Aug 2007 Dep Older (55+) 31 Chronic disease - dep: RR = 1.5, 95% CI 1.2 to 2.0. poor SRH - dep: RR = 2.4, 95% CI 1.9 to 3.0. Chronic disease - dep: RR = 1.5 (1.2 to 2.0) SRH - dep: RR = 2.4 (1.9 to 3.0)   Review
- Not hand-search journals, no attempt to identify unpublished studies, three databases, only English
- Heterogeneity in results
5
Almeida [45]   Dep Older (70+) 17 High tHcy increased risk of dep: OR = 1.7, 95% CI 1.4 to 2..1 TT vs. CC carriers: OR = 1.2, 95% CI 1.0 to 1.5 High tHcy - dep: OR = 1.7 (1.4 to 2.1)
MTHFR C677T - dep: TT vs CC: OR = 1.2 (1.0 to 1.5) CT vs CC: OR = 1.1 (0.9 to 1.2)
- Sufficiently powered randomised trials Original studies
- Small sample size (trials)
- Reverse causality (observation studies)
- Inconsistent definition phenotype, misclassification bias (genetic studies)
- Lack of reliable information on ethnicity
Review
- Meta-analysis lacked power
4
Stetler [46] May 2009 Dep Adult 414 Dep vs no dep: Cortisol d = 0.6 (95% CI 0.5 to 0.7) Adrenocorticotropic-releasing hormone d = 0.28 (95% CI 0.2 to 0.4) Corticotropin-releasing hormone d = 0.02 (95% CI -0.5 to 0.5) Too many results - Bioinformatic technologies
- Larger sample size
- Longitudinal
Original studies
- High degree of heterogeneity
- Publication bias possible
- Based on cross-sectional studies
- Arbitrary criteria for minimal methodological quality
- Most of the included studies were underpowered
3
Kuo [47] Sep 2004 Dep Adult 19 High concentrations C-reactive protein predictive of cognitive decline and dem. Relations to dep cross and not consistent. - - Prospective study c-reactive protein-dep
- Intervention studies to lower c-reactive protein and improved outcomes
NR 3
Kuo [41] Mar 2004 Dep Older (55+) NR Growing evidence of association hyper-homocysteinemia and cognitive impairment, dem and dep. Proposed mechanisms include angiotoxicity, neurotoxicity, and inhibition of collagen cross-linking - - Role of homocysteine in prevention
- Prospective studies association with dep
- Adequate adjustment for possible confounders
NR 3
Camus [48] Jun 2003 Dep Older NR Potential ways association dep - vascular disease: 1 direct influence vascular disease, 2 direct influence dep, 3 common causes - - Pathophysiological and genetic background of vascular depression NR 1
Vink [49] Dec 2005 Anx
Dep
Older (50+) 80 Risk factors anx and dep showed many similarities but some differences were found. Biological factors may be more important in predicting dep, and a differential effect of social factors on dep and anx was found. - - Intervention (whether manipulation of risk factors reduces the onset of anx/dep)
- Clearer understanding of etiological factors differentiating anx and dep
Review
- Heterogeneity between studies, no meta-analysis
- Only main effects of risk factors on anx and dep
- Heterogeneity limits comparison across studies
- Risk factors that have not yet been studied
- No distinction made between different anx disorders
1
Risk factors
Chen [20] Jun 1997 Dep Older (60+) 10 The patterns of risk factors were similar to those in western countries See prevalence See prevalence See prevalence 4
Meeks [30] Jan 2010 Dep Older (55+) 153 Risk factors: female, medical burden, disability and low social support; neurological illnesses (Parkinson's disease, stroke, AD) - - While some risk factors are well established, others remain to be identified. See prevalence 2
Djernes [31] Sep 2004 Dep Older (65+) 122 Risk factors: female, somatic illness, cognitive and functional impairment, lack of social contacts, history of dep - See prevalence See prevalence 2
Cole [50] 2001 Dep Older (50+) 20 Risk factors, Qualitative: disability, new medical illness, poor health status, prior depression, poor self-perceived health, and bereavement. Quantitative: bereavement, sleep disturbance, disability, prior depression, female gender 13 risk factors investigated. OR ranged from 1.0 to 3.3, significant risk factors: bereavement, sleep disturbance, disability, prior dep, female gender - Intervention Original studies
- Follow-up incomplete in most studies
- Differences in the length of follow-up
- Differences in definitions risk factors and adjustment
- Many potential risk factors not studied adequately
- Cumulative effect of multiple risk factors not studied
- Heterogeneity in the results
Review
- Search by one author only
- Only English or French literature
- Did not assess publication bias
- Abstracted by one author
2
Vink [49] Dec 2005 Anx, Dep Older (50+) 80 Risk factors both anx and dep: personality, coping strategies, previous psychopathology, social network, stressful life events, female. Dep: smaller network size, being unmarried. - See biological See biological 1
Disease outcome
Meeks [30] Jan 2010 Dep Older (55+) 153 Consequences: disability, greater healthcare utilisation, increase suicide ideation - - More sophisticated health economic studies See prevalence 2
Alwahhabi [32] 2001 Anx Older (55+) 119 Limitations: understanding expression anx, variable definitions elderly, diagnostic instruments. Anx in elderly potential for negative consequences independent of comorbidity major dep. - - Definition of elderly
- Symptom definition and diagnostic instruments
- Clinical trials
Original studies
- No common definition of the lower limit of geriatric age
1
  1. AD, Alzheimer's disease; Agg, aggression; Anx, anxiety; BPS, behavioural and psychological symptoms; Cross, Cross-sectional; Dem, Dementia; Dep, depressive symptoms; Ela, elation; Long, longitudinal; MCI, mild cognitive impairment; Prev, prevalence; Psy, psychosis; Sle, sleep problems; SRH, self-rated health