Major depression can be regarded as a systemic neurobehavioral disorder resulting from dysfunction of the limbic-cortical networks. The cingulum bundle represents a major association fiber tract of those networks. The aim of our study was to determine the association of brain structural tissue markers of the cingulum bundle and cognitive function in patients with major depression.

Region-of-interest-based analyses of the middle-anterior and middle-posterior cingulum bundle fractional anisotropy (FA) and mean diffusivity (MD) using color-coded diffusion-tensor imaging and neuropsychological assessment in 14 patients with major depression.

FA of the middle-anterior and middle-posterior cingulum bundle was significantly correlated to the performance in a planning and divided attention task. Furthermore, MD of the middle-posterior cingulum bundle was significantly correlated to a planning task. There was no significant correlation between FA and MD of the cingulum bundle and selective attention or memory.

Brain structural tissue markers of the middle-anterior and middle-posterior cingulum bundle were found to be associated with executive functioning and divided attention in patients with major depression. Disconnection within the limbic-cortical networks may underlay cognitive dysfunction in major depression.

Many commonly prescribed drugs have anticholinergic properties which can induce side-effects e.g. delirium, especially in an ageing brain with increased sensitivity. Risk-assessment before starting therapy may prevent such sideeffects.

We rated anticholinergic pharmacological properties of prescribed medication and compared the theoretical risk with side-effects in clinical practice.

The scale should improve the safety of pharmacotherapy in gerontopsychiatry.

Based on five publications that considered anticholinergic properties of drugs, a risk-scale was established. Riskpoints for all drugs were summarized to a total score. Patients were selected from TDM-requests and data on patients’ sideeffects obtained from medical files. Reported anticholinergic side-effects including delirium were assessed retrospectively by the UKU-rating scale. Using linear regression and Spearman's correlation-analysis a possible correlation between risk-score points and severity of side-effects was determined.

The screened sample consisted of 53 patients. 38 patients aged from 64 to 89 years (mean 74±6, 63.2% women) could be included for analysis. They had 93 plasma-level determinations (mean 2.4 requests per patient). According to their medication, patients attained by mean 4.51±2.98 risk-points (range 0-16). Mean UKU severity-index of side-effects was 0.81 (±0.99). Risk-points correlated significantly with observed anticholinergic side-effects and delirium (R2=.631, P< 0.001, CI 95%). Spearman correlation-coefficient was 0.731 (P< 0.01, CI 95%).

Since the established risk-scale correlated well with reported anticholinergic side-effects we recommend to implement this in the planning of psychopharmacological treatment to improve the safety of pharmacotherapy in gerontopsychiatry. For practical reasons it should be amalgamated with therapeutic drug monitoring as Geronto-TDM.

Dementia and cognitive impairment are associated with higher rates of complications and mortality during hospitalization in older patients. Moreover, length of hospital stay and costs are increased. In this prospective cohort study, we investigated the frequency of hospitalizations caused by ambulatory care-sensitive conditions (ACSCs), for which proactive ambulatory care might prevent the need for a hospital stay, in older patients with and without cognitive impairments.

Prospective cohort study.

Eight hospitals in Germany.

A total of 1,320 patients aged 70 years and older.

The Mini-Cog test has been used to assess cognition and to categorize patients in the groups no/moderate cognitive impairments (probably no dementia) and severe cognitive impairments (probable dementia). Moreover, lengths of hospital stay and complication rates have been assessed, using a binary questionnaire (if occurred during hospital stay or not; behavioral symptoms were adapted from the Cohen-Mansfield Agitation Inventory). Data have been acquired by the nursing staff who received a special multi-day training.

Patients with severe cognitive impairments showed higher complication rates (including incontinence, disorientation, irritability/aggression, restlessness/anxiety, necessity of Tranquilizers and psychiatric consults, application of measures limiting freedom, and falls) and longer hospital stays (+1.4 days) than patients with no/moderate cognitive impairments. Both groups showed comparably high ACSC-caused admission rates of around 23%.

The study indicates that about one-fourth of hospital admissions of cognitively normal and impaired older adults are caused by ACSCs, which are mostly treatable on an ambulatory basis. This implies that an improved ambulatory care might reduce the frequency of hospitalizations, which is of particular importance in cognitively impaired elderly due to increased complication rates.

Diagnostic criteria and empirical evidence support the existence of cognitive deficits in depression. However, depressed mood, loss of interest and low self-efficacy might influence cognitive performance.

Goal-setting instructions were used to promote motivation in depressed patients and control subjects during neuropsychological assessment. The resulting performance was compared with performance using standard instructions. Sixty in-patients with non-psychotic unipolar depression and 60 age- and education-matched healthy control subjects were assessed with standard neuropsychological tests [the Auditory Verbal Learning Test (AVLT), the Digit Symbol Test (DST), the Regensburg Word Fluency Test (RWT), and the Number Combination Test (Zahlen-Verbindungs-Test, ZVT)] using either goal-setting or standard test instructions.

Depressed patients showed lower baseline performance and lower generalized self-efficacy (p<0.0005) than controls. However, goal-setting instructions significantly improved patients' memory performance by 10% [AVLT: F(5, 54)=3.611, p=0.007] and psychomotor performance by 13% [ZVT: F(3, 56)=3.667, p=0.017]. Consequently, patients and control subjects demonstrated similar results when goal-setting instructions were applied. Goal-setting instructions showed a statistical trend, increasing patients' performance in the DST by 12% [F(1, 58)=2.990, p=0.089], although their verbal fluency measured by the RWT did not increase. No significant correlations of increased performance with generalized self-efficacy were found.

Cognitive deficits in depressed patients are influenced by motivational shortcomings. Because generalized self-efficacy failed to correlate to increased test performance, future research needs to disentangle the effective components of goal-setting instructions. Task-specific self-efficacy as well as enhancement of task-focused attention might underlie the significant goal-setting effect in depressed patients.