Geriatric Mental State Examination Research Articles

Subjective worsening of memory predicts dementia after three years

ABSTRACTStudy Objective: Design: Setting: Paricipants: Measurements: Results: Conclusions: Key words: aged, 75 years and over; subjective memory impairment; prospective study; dementiaElderly persons expressing a worsening of memory function are at increased risk ofdeveloping dementia.When adjusting for potential confounding by depressive symptoms, two of the GMSquestions scored at baseline, 'Is it more difficult to remember things than it used to be?' and 'Do youwrite reminders to yourself more often now than before?', were significant predictors of dementiawithin three years, OR = 3.3, 95% CI = 1.2–8.6 and OR = 2.8, 95% CI = 1.0–7.6, respectively.Dementia (DSM-III and DSM-III-R criteria).285 non-demented persons aged 75 years and above at start of study, 77.5% women.Persons living at home.Prospective study of a random sample of older people with follow-ups after three, six, nineand twelve years.To assess whether complaining of memory impairment, as measured by the subjectivepart of the Geriatric Mental State examination (GMS, the Canberra community version), predictslater development of dementia.

Subjective Memory Deficits in People with and without Dementia: Findings from the 10/66 Dementia Research Group Pilot Studies in Low‐ and Middle‐Income Countries

To compare subjective memory deficit (SMD) in older adults with and without dementia or depression across multiple centers in low- and middle-income countries (LAMICs). Secondary analysis of data from 23 case control studies. Twenty-three centers in India, Southeast Asia (including China), Latin America and the Caribbean, Nigeria, and Russia. Two thousand six hundred ninety-two community-dwelling people aged 60 and older in one of three groups: people with dementia, people with depression, and controls free of dementia and depression. SMD was derived from the Geriatric Mental State examination. Median SMD frequency was lowest in participants without dementia (26.2%) and higher in those with depression (50.0%) and dementia (66.7%). Frequency of SMD varied between centers. Depression and dementia were consistently associated with SMD. Older age and hypochondriasis were associated with SMD only in subjects without dementia. In those with dementia, SMD was associated with better cognitive function, whereas the reverse was the case in controls. Associations with SMD may differ between subjects with and without dementia living in LAMICs.

Is the relationship between syndromes of depression and dementia temporal? The MRC-ALPHA and Hefei-China studies

Recent studies have shown a temporal association between depressive symptoms and cognitive decline. However, the relationship between syndromes of depression and dementia is unknown. A total of 1736 people aged > or = 65 years in China and 5222 older people in the UK were interviewed using the Geriatric Mental State Examination (GMS) and reinterviewed at follow-up. Five levels of syndromes of depression and dementia were diagnosed using the Automated Geriatric Examination for Computer Assisted Taxonomy (AGECAT). Although there were fewer depressive syndromes in Chinese than British participants, both populations showed a similarly high level of syndromes of dementia (organic disorder) (20% for women, 14% for men). There was a significant cross-sectional correlation between syndrome levels of depression and dementia (correlation coefficients: 0.141-0.248 for Chinese, 0.168-0.248 for British). This was maintained for different age, gender and people with and without cardiovascular disease (CVD). The relationship between syndromes of baseline depression and follow-up dementia was less substantial: the correlation coefficient was 0.075 [95% confidence interval (CI) 0.021-0.128] for the Chinese sample at the 1-year follow-up, and 0.093 (95% CI 0.061-0.125) for the British at the 2-year follow-up and 0.093 (95% CI 0.049-0.130) at the 4-year follow-up. This relationship disappeared in participants without baseline organic syndromes. In a multiple adjusted logistic regression analysis, an increased risk of organic syndromes seemed to be associated with baseline, mainly in the highest level of, depressive syndromes. The relationship between syndromes of depression and dementia might be temporal. The lack of an obvious dose-response relationship between baseline depressive syndromes and follow-up dementia syndromes suggests that the causal relationship between depression and dementia needs further investigation.

Subsyndromal depression in old age: clinical significance and impact in a multi-ethnic community sample of elderly Singaporeans

This cross-sectional study examined the clinical significance and impact of subsyndromal depression in a sample of elderly people living in the community in Singapore. Data were analyzed from a population survey (the Singapore National Mental Health Survey of the Elderly). A total of 1092 respondents from a nationally representative multi-ethnic (Chinese, Malay and Indian) stratified random sample of older adults aged 60 and above were examined for depression using the Geriatric Mental State Examination (GMS). Diagnostic confidence levels of 3-5 indicated a DSM-IV diagnosis of syndromal depression, and 1-2 indicated subsyndromal depression. Other variables included sociodemographic characteristics, psychiatric and medical comorbidities, MMSE, health awareness, health and functional status. Subjects with subsyndromal depression were more likely to have poor socioeconomic status, cognitive impairment, anxiety, and measures of poor mental, physical and functional status compared with non-depressed subjects, and were similar to or worse than syndromal cases. In multivariate analyses that controlled for age, gender, ethnicity, education and several other sociodemographic factors, both subsyndromal and syndromal depression were significantly associated with higher numbers of medical comorbidities, diagnoses of comorbid dementia and anxiety, lower MMSE scores, self-reported mental health problem, functional disability and poor health status. In this Asian population, subsydromal depression had the same clinical significance and health impact as syndromal depression, similar to findings in the West.

Prevalence and symptomatology of depression in older people living in institutions in England and Wales

Epidemiological studies have shown that depression is common in institutional settings. However, the symptomatology of depression in this group has not been compared to those living in the community. To estimate the prevalence of depression and depressive symptomatology in participants living in institutions and compare these to people living in other settings. The Medical Research Council Cognitive Function and Ageing Study (MRC CFAS) is a population-based cohort comprising 13,004 individuals aged 65 and above, from five sites across England and Wales. Following screening, a stratified random sub-sample of 2,640 participants received the Geriatric Mental State (GMS) examination of whom 340 resided in institutions. Diagnoses of depression were made using the Automated Geriatric Examination for Computer-assisted Taxonomy system (AGECAT). The prevalence of depression in those living in institutions was 27.1% (95% CI 17.8-36.3) compared to 9.3% (95% CI 7.8-10.9) in those living at home. Symptoms relating to depressed mood, severity of illness (e.g. wishing to be dead, future looking bleak) and some non-specific symptoms were more common in those living in residential homes. Depression was significantly associated with younger age (P = 0.002) and high functional disability (P = 0.009) in those living in institutions. Consistent with previous estimates, depression was highly prevalent in institutions, particularly in younger individuals with severe functional impairment. Those in institutions report considerably more symptoms of depression. Finding interventions which address these symptoms might improve quality of life for people in institutions, irrespective of formal diagnoses.

Co‐occurrence of anxiety and depressive disorders in a community sample of older people: results from the MRC CFAS (Medical Research Council Cognitive Function and Ageing Study)

Few population-based studies have examined the whole range of subthreshold syndromes and disorders of anxiety and depression in older people. To investigate the co-occurrence of anxiety and depressive syndromes in older people. Associations between these conditions and personal and environmental factors are examined. MRC CFAS included 13,004, age 65 years and above, who completed the initial screening interview. A stratified random subsample of 2,640 participated in the assessment interview where the Geriatric Mental State Examination (GMS) was administered. The AGECAT diagnostic system was used to generate subthreshold and disorder-level of anxiety and depression as well as the combination of these into eight syndromes categories plus a group without any of the syndromes categories. Prevalences, unadjusted and adjusted odds ratios are calculated for the syndrome categories in relation to cross-sectional personal and environmental factors, and odds ratios of subthreshold and disorders level are estimated. The overall prevalence of anxiety and depressive disorders are 3.1% and 9.7% respectively. The overall prevalence of either anxiety or depressive disorder (anxiety disorder with subthreshold depression, mixed anxiety and depressive disorder with subthreshold anxiety) where they overlapped is 8.4%. The highest Odds Ratios unadjusted and adjusted for age and gender, of anxiety and depressive disorders and significant for trend are found for increasing disability. Disability has a strong relationship with all the co-morbid syndrome categories. In all analyses women showed significant higher estimates than men. Our study demonstrated high estimates where anxiety and depression occurred in parallel both as disorders and as subthreshold syndromes.

Prevalence of depression in older people in England and Wales: the MRC CFA Study

Depression in old age is an important public health problem. The aims of this study were to report the prevalence of depression in the Medical Research Council Cognitive Function and Ageing Study (MRC CFAS), a community-based, cohort. Following screening of 13 004 people aged 65 and over from a population base, a stratified random subsample of 2640 participants received the Geriatric Mental State (GMS) examination and were diagnosed using the Automated Geriatric Examination for Computer-Assisted Taxonomy (AGECAT) algorithm. The prevalence of depression was 8.7% [95% confidence interval (CI) 7.3-10.2], increasing to 9.7% if subjects with concurrent dementia were included. Depression was more common in women (10.4%) than men (6.5%) and was associated with functional disability, co-morbid medical disorder, and social deprivation. Prevalence remained high into old age, but after adjustment for other associated factors, it was lower in the older age groups. The prevalence of depression in the elderly is high and remains high into old age, perhaps due to increased functional disability.

Can nurses help identify patients with depression following stroke? A pilot study using two methods of detection

This paper reports a study to determine the accuracy of the Geriatric Mental State examination and the Montgomery-Asberg Depression Rating Scale, when administered by a nurse, in detecting depression in patients who have recently had a stroke. After a stroke, survivors spend considerable amounts of time in the direct care of nurses. Many show signs of depression, and this has been associated with an adverse effect on recovery and rehabilitation. Identifying those with depression when they have communication and cognitive difficulties is especially difficult. Treatments are available to assist in the management of depression, and early detection and intervention may assist in this process. A cross-sectional pilot study was conducted, comparing (a) clinical diagnosis of depression by a psychiatrist with (b) two clinical interviews, using the Geriatric Mental State examination and the Montgomery-Asberg Depression Rating Scale, conducted by a nurse. The data were collected in 2002. Twenty-eight patients, who were still in hospital in the second week poststroke, were included. The median age was 72 (interquartile range: 61-78). There were 14 males. The psychiatrist rated seven (25%) patients as depressed. The Geriatric Mental State examination had a sensitivity of 71%, a specificity of 67%, a positive predictive value of 42%, a negative predictive value of 88% in detecting depression and an overall efficiency of 68%. The Montgomery-Asberg Depression Rating Scale had a sensitivity of 100%, a specificity of 65%, a positive predictive value of 54%, a negative predictive value of 100% and an overall efficiency of 75%. In this study, the Geriatric Mental State examination and the Montgomery-Asberg Depression Rating Scale were at least as efficient at detecting the depression in patients who have had a stroke. However, as the Montgomery-Asberg Depression Rating Scale is quicker to administer, it may prove more useful to nurses clinically.

The Geriatric Mental State Examination in the 21st century.

The Geriatric Mental State Examination (GMS) is now established as one of the most commonly used mental health assessments for older people. Its strengths lie in extensive validity studies, high inter-rater reliability, accessibility to trained raters, irrespective of professional background and its continual evolution and adaptation. Its computerisation, association with supplementary instruments and support by a diagnostic algorithm provides a comprehensive diagnostic system and syndrome profile for each subject. The instrument has been validated against most major diagnostic systems and has been used as outcome measures in intervention studies. It has been translated into numerous languages and validated as a diagnostic instrument in various cultures. Such studies have exposed weaknesses, including the over diagnoses of organic states in populations with poorly developed education. On-going studies continue to address these issues, providing a culture sensitive instrument enabling unique trans-cultural research in a relatively under-researched field.

Birth weight and the risk of depressive disorder in late life.

Low birth weight is a risk factor for coronary heart disease, diabetes, stroke and hypertension. Depression is highly associated with these conditions. To examine the association between birth weight and depression in late life. A total of 882 singleton term births in the 1920s had contemporary records of birth weight and weight at 1 year. At 68 years all completed the Geriatric Depression Scale and 867 completed the Geriatric Mental State Examination. A logistic regression was used to analyse the associations between depression, birth weight and weight at 1 year while adjusting for known risk factors. Current social class, social class at birth, recent bereavement, social isolation and physical illness increased the risk of depression. After adjusting for these and weight at 1 year, the odds ratios for depression among men, but not women, rose incrementally with decreasing birth weight (1.0, 12.8; for continuous variable, P<0.007). Foetal undernutrition predisposes men to depression in late adult life. If replicated, these results would suggest a neurodevelopmental aetiology of depression, possibly mediated by programming of the hypothalamic-pituitary-adrenal axis.

Mild dementia or cognitive impairment: the Modified Mini-Mental State examination (3MS) as a screen for dementia.

To examine the Modified Mini-Mental State Examination (3MS) as a screen for dementia. A group of 1092 elderly Edmonton community residents completed the 3MS and the Geriatric Mental State Examination (GMS). 3MS sensitivity and specificity were determined by comparing positive 3MS screens (score < or = 77) with those classified as GMS "organic" (severity level 3, equivalent to a clinical diagnosis). In the Canadian Study of Health and Aging (CSHA), 2914 subjects received the 3MS and a clinical examination. A group described as having "cognitive impairment but no dementia (CIND)" was identified. In Edmonton, the 3MS showed 88% sensitivity, 90% specificity, 29% positive predictive value (PPV), and 99% negative predictive value (NPV). In the CSHA, 30% of subjects receiving both the 3MS and a clinical examination were classified as CIND. One-half of these were classified as having "age associated memory impairment (AAMI)" or as "unspecified." The 3MS with a cutting score of 77/78 proved a reasonable screening instrument; 1 case in 3 screening "positive" has dementia, but few (0.64%) will be missed by screening "negative." CIND, accounting for 2 out of 3 cases screened positive by the 3MS in the Edmonton study, is a substantial, heterogeneous group that is not necessarily "predementia" but that in many cases merits further investigation.

Natural history of pharmacotherapy of older depressed community residents. The MRC-ALPHA Study.

Depression in older people is common and has a high mortality, but effective treatments exist. To describe drug prescribing in older community residents in relation to depression status. The MRC-ALPHA community cohort aged 65 and over were interviewed using the Geriatric Mental State examination drug data collected at index interview and at two and four years. Antidepressants were used by 10.9% of the depressed population. Benzodiazepines were used frequently. Of the antidepressant users, 59.6% took low-dose antidepressants for two years, had a poor outcome and few drug changes. Trends of increasing antidepressant use have cost implications for primary care groups. Benzodiazepines may be mis-prescribed for treatment of depressive symptoms. Antidepressant users have poor outcome and follow-up.

New methods in psychiatric epidemiology.

Research on the epidemiology of mental disorders has now reached the stage where it is possible for comparisons to be cautiously made between population samples. This is made possible for the following reasons: recognition that the populations at risk, including their age composition and exclusions, must be clearly specified; the use of the standardized diagnostic criteria in international use (ICD-10 and DSM-IV); and standardized clinical assessments, such as the Schedule for Clinical Assessment in Neuropsychiatry, the Diagnostic Interview Schedule (DIS) or Composite International Diagnostic Interview (CIDI), including the automated CIDI-A, and for the elderly, the Geriatric Mental State Examination and the Canberra Interview for the Elderly. Some recommendations are made for future epidemiological studies, including these advances in methodology. Emphasis is given to the value of using continuous measures of symptoms, in addition to categorical diagnoses. In research on etiology, investigators should make every effort to test innovative hypotheses, particularly where these involve both biological and psychosocial variables.

The effects of intelligence and education on the development of dementia. A test of the brain reserve hypothesis

A number of recent epidemiological studies have shown that the prevalence and incidence of dementia are increased in population strata with low compared to high levels of education. This has been explained as a consequence of a greater 'brain reserve capacity' in people with a high level of education. Theoretically, however, brain reserve capacity is better reflected by intelligence than by level of education. Thus, the emergence of dementia will be better predicted by low pre-morbid intelligence than by low education. This prediction was tested in a population based sample of elderly subjects (N = 2063; age range 65-84; Amsterdam Study of the Elderly) who were followed over 4 years. Dementia was diagnosed using the Geriatric Mental State examination (GMS). Pre-morbid intelligence was measured using the Dutch Adult Reading Test (DART), a short reading test which gives a good estimate of verbal intelligence, and is relatively insensitive to brain dysfunction. The effects of age, gender, occupational level, number of diseases affecting the central nervous system and family history of dementia or extreme forgetfulness were also examined. Logistic regression analysis showed that low DART-IQ predicted incident dementia better than low level of education. A high occupational level (having been in charge of subordinates) had a protective effect. This result supports the brain reserve theory. It also indicates that low pre-morbid intelligence is an important risk factor for cognitive decline and dementia. Use of reading ability tests is to be preferred over years of education as estimator of pre-morbid cognitive level in (epidemiological) dementia research.

Prevalence of dementia and depression among elderly people in black and ethnic minorities.

This study was designed to identify all elderly people of ethnic minorities living in a defined geographical area in inner-city Liverpool and to identify psychiatric morbidity and barriers to use of services. This paper reports the prevalence of dementia and depression. A survey of the community was carried out using the Geriatric Mental State Examination, AGECAT and ethnically matched interviewers. The sampling frame consisted of Family Health Services Authority lists as a basis, with additional information from community lists, 'snow-balling' and a door-to-door survey. 418 people were interviewed, with a high percentage (55%) of young elderly (65-74) men. The prevalence of dementia ranged from 2 to 9% and of depression from 5 to 19%, and there were no significant differences in levels between English-speaking ethnic groups and the indigenous population. Higher levels of dementia were found among non-English-speaking groups. A complete enumeration of the elderly in ethnic minority groups is best achieved by using several different methods. Diagnosis of dementia may be misleading among those who do not speak the dominant language.

Psychiatric morbidity in the oldest old. Results of the Berlin Aging Study

An increasing life expectancy leads to a higher number of persons aged 70-84 years and persons aged 85 years and older. Information concerning changes in the spectrum of psychiatric morbidity is rare. The Berlin Aging Study was based on a representative age- and gender-stratified sample (n = 516) of Berlin citizens aged 70-100 years and older. In this inter-disciplinary study, an intensive investigation was carried out by psychologists, sociologists, internists and psychiatrists. This report focuses on subjectively reported complaints (Beschwerdeliste, BL), observed psychopathological symptomatology (Brief Psychiatric Rating Scale, BPRS) and psychiatric diagnoses following the criteria of DSM-III-R (based on the Geriatric Mental State Examination, GMSA). On the self-rating scale (BL) 10% of all persons reported severe subjective complaints, 32% moderate complaints. On the BPRS, 17% showed severe psychopathological symptomatology, 75% at least mild symptoms. Following the criteria of DSM-III-R, 23.5% of all persons had a psychiatric disease, 4.2% a disease of severe intensity. When the DSM-III-R diagnoses "Not Otherwise Specified" (NOS) were included 40.4% of all subjects were diagnosed by the clinical judgement of the psychiatrists to have a psychiatric disease. The most frequent psychiatric diseases were insomnia (18.8%), depression NOS (17.8%) and dementia (13.8%). Dementia showed the well-known age-related increase, whereas no other incidences of psychiatric morbidity were age-related. Persons aged 70-84 years did not differ in the investigated psychiatric variables from persons aged 85 years and older, the only exception being the prevalence of dementia.

Prospective data on the prevalence of abnormal involuntary movements among elderly people living in the community.

Trained raters from the Liverpool Continuing Health in the Community study interviewed 1070 people over the age of 65 in 1982-1983 using the Geriatric Mental State (GMS) examination. Three years later the cohort was re-interviewed, this time by psychiatrists trained in the GMS, who used the GMS and the History and Aetiology Schedule (HAS). The cohort had fallen in size to 875, because of mortality; 701 were re-interviewed. The cohort was followed up again 6 years after the first interview by trained nurse raters using the GMS (A3) and the Mini-Mental State Examination. Cases of mental disorder identified by the computer diagnostic program AGECAT were re-interviewed by psychiatrists along with a number of controls using the GMS and the HAS on the remaining 450 individuals. Observational behavioural ratings from the GMS and summary sheets were analysed along with AGECAT diagnoses and data on medication gained at the 3 assessments. The community prevalence of tardive dyskinesia and other movement disorders in elderly people over a 6-year follow-up appears to be very low (the community prevalence of tardive dyskinesia being 0.22% and akathisia 1.57%), is usually associated with organic mental disorder (and consequently higher mortality) and is furthermore not usually associated with antipsychotic medication.

Prevalenza dei disturbi affettivi (DSM-IIIR) nei pazienti di un reparto di medicina geriatrica. Uno studio epidemiologico con controlli della popolazione generale

SummaryObjective - To investigate the rate of DSM-IIIR main affective disorders in a sample (52) of elderly medical patients consecutively admitted to a geriatric ward; to look for risk factors associated with depression; to compare the rate of depression with the one detected in community controls (117 subjects). Design - All consecutive patients admitted during January-February 1990 were assessed with a standardized psychiatric interview (Geriatric Mental State Examination) and with the Mini-Mental State Examination. Setting - The IV Geriatric Division (ward and day-hospital), Ospedale Civile Maggiore of Verona, which cares for elderly affected by medical illnesses. Main outcome measures - Depression was diagnosed according to the main DSM-IIIR categories for mood disorders. Results - Overall, an affective disorder was diagnose in 25% of the subjects (major depression 5,7%, dysthymic disorder 3,8%, n.o.s. depression 13,4%, adjustment disorder with depressive mood 1,9%). This rate was significantly higher when compared with the prevalence detected in community controls (25% vs. 11,1%). Older age, female sex, physical disability and distressing events were not associated with affective illness, while the lack of social support was significantly associated with depression. Conclusions - Elderly medical patients turned out to be an high risk group for depression, which deserves psychiatric screening and specific treatment.

Epidemiology of depressive symptoms in elderly primary care attenders.

408 elderly primary care attenders were screened using the Geriatric Depression Scale (GDS) and the 30-item General Health Questionnaire (GHQ). 36% were identified as 'cases' on the GDS and 32% on the GHQ. The 'cases' and a random sample of 'non-cases' were interviewed using the Geriatric Mental State Examination (GMS), the Bedford College Life Events and Difficulties Interview (LEDS), the National Adult Reading Test (NART), and systematic inquiry concerning physical health. Sensitivity and specificity of the GDS were 85% and 68%, and of the GHQ 77% and 67%. General practitioner identification of cases showed a sensitivity of 78% and a specificity of 60% against the GMS. Depression was significantly associated with life events, chronic difficulties, poor physical health and current lack of a confiding relationship. Subjective complaints of depression were associated with low premorbid intelligence and lifelong lack of a confiding relationship. The availability of a confiding relationship appears to have a protective effect against depressive illness associated with life events and chronic difficulties.

Interobserver reliability of the italian version of the geriatric mental state examination

AbstractThe Italian version of the Geriatric Mental State Examination (GMS) was tested for interrater agreement (interobserver). Thirty geriatric patients form psychiatry, neurology and general medical facilities were interviewed by four raters. The mean values of kappa and phi for the analysable items were 0.80 and 0.81. ‘Organic’ and ‘functional’ items produced very similar coeffcient values.