White Coat Notes

Depression may increase risk of dementia, study says

July 12, 2010

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Dementia and depression can be constant companions in old age, but which comes first has been puzzling. The research literature is inconsistent, sometimes suggesting that declining mental powers plunge an older person into despair and other times supporting the idea that depression might pave the way for dementia.

A new study that followed participants in the long-running Framingham Heart Study lands squarely on the side of depression as a risk factor for later dementia. Being depressed increased the risk of dementia by more than half, Jane Saczynski of the University of Massachusetts Medical School and colleagues from Boston University reported last week in the journal Neurology.

To untangle the connection, the researchers tested 947 elderly people who had no signs of cognitive impairment at the start of the study. They were screened for depression at the outset and 125 scored high enough to be considered depressed.

Seventeen years later, 164 people had developed dementia, including 136 who were diagnosed with Alzheimer’s disease. Twenty-two percent of the people who were depressed at the study’s start developed dementia, compared with 17 percent who were not depressed. Looking at how people scored on the 60-point depression screening test, the researchers found that for each 10-point increase, there was a 50 percent increased risk of dementia. After accounting for age, sex, and other characteristics among the participants, it was determined that depressed people were more than one and a half times more likely to develop dementia than those not depressed.

“We have such long follow-up in our study, it lends support to depression as a risk factor for dementia and not merely a consequence,’’ Saczynski said in an interview. “Everyone wants to find risk factors for dementia and know what increases risk. Here we identify one more risk factor.’’

The study can’t say that depression causes dementia, Saczynski said, but it spurs greater interest in understanding what biological mechanisms might be related to both depression and dementia.

“The association between late-life depression and cognitive impairment does not appear to be spurious,’’ Dr. Yonas Geda of the Mayo Clinic writes in an editorial also appearing in Neurology, referring to Saczynski’s study and two others with consistent results. “However, there is insufficient evidence at present to support the hypothesis that depression has a direct causal relationship with subsequent dementia. Only a future mechanism of disease study with a biologic marker for depression can clearly identify which of the . . . hypotheses is most pertinent.’’

Meanwhile, doctors, patients, and family members can be alert to depression as a possible predictor of dementia, Saczynski said. They can consider improving diet, sleep, and social engagement, factors that might ease depression and dementia. “It could be beneficial on both fronts,’’ she said. ELIZABETH COONEY

Generic drug policies could save $100m nationally, study says

When blockbuster drugs lose their patent protection, state Medicaid programs can save millions of dollars by switching patients to generic versions. A study in this month’s Health Affairs concludes that some states, including Massachusetts, are quicker than others to bring down the costs of drugs once alternatives are available.

Dr. William Shrank of Brigham and Women’s Hospital led a team from Harvard, Mount Sinai School of Medicine, and pharmacy company CVS Caremark that looked at what happened when Zocor’s patent expired in 2006 and generic versions of the cholesterol-lowering statin became available. In states that did not require patient consent for substituting simvastatin, 98 percent of prescriptions were filled with the generic drug, compared to less than a third in states that required consent.

Medicaid programs nationally could have saved $19.8 million if they all had generic-substitution policies that did not need patient consent, the authors conclude. Once Lipitor, Plavix, and Zyprexa go off patent, the savings could total $100 million nationwide. E.C.

Sports medicine sites don’t all measure up, review says

Say you’ve got a shoulder injury your doctor says may need surgery. Where do you turn for help?

If you’re like most Americans, you consult Dr. Google, or her colleague Dr. Yahoo. But writing in the Journal of Bone and Joint Surgery, Dr. Madhav Karunakar and colleagues from the Carolinas Medical Center in Charlotte, N.C., report that nonprofit sites and academic sites were better than news-related or personal sites when it came to accuracy of information on typical knee, shoulder, elbow, or other joint injuries. Commercial sites, with the notable exception of WebMD and eMedicine, were the worst, they said, promoting their products and omitting possible complications.

The poor showing was no surprise to Dr. Brian McKeon, an orthopedic surgeon at New England Baptist Hospital and team physician for the Boston Celtics.

“These sites don’t know what [the patient’s] MRI looks like,’’ McKeon said. “What they in particular have, and the intricacies of their particular problem, don’t fit on any website. Nothing ever is as solid as a physical exam.’’


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