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Psychiatry Research xxx (2011) xxxxxx

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Psychiatry Research
j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / p s yc h r e s

Brief report

Life events and dementia: What is the nature of their relationship?

Konstantinos N. Fountoulakis a,, Ioannis Pavlidis b, Magda Tsolaki c
a
b
c

3rd Department of Psychiatry, School of Medicine, Aristotle University of Thessaloniki, Greece

IKA, Central Polyclinic of Thessaloniki, Greece
3rd Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, Greece

a r t i c l e

i n f o

Article history:
Received 23 March 2010
Received in revised form 25 March 2011
Accepted 8 May 2011
Available online xxxx
Keywords:
Dementia
Life events

a b s t r a c t
The current study analyzed the life events reported by 1271 demented patients vs. 140 cognitively healthy
elderly subjects. The Life Change Unit (LCU) method was used to quantify the results. When all the events
were included in the analysis, the two groups had similar LCU scores (61.26 vs. 63.42). However, when events
causally related to dementia (e.g. stroke) are excluded, demented patients were found to experience half of
the LCU load in comparison to controls (30.70 vs. 63.42). In both groups the level of LCU load is far below 100
which is the threshold suggested for the induction of psychosomatic disorders. Conclusively, the current study
suggests that there is no causal role for life events in the etiopathogenesis of dementia. On the contrary,
demented patients even the last few months before the clinical onset of dementia experience low life-eventsrelated stress, possibly because of subclinical impairment which is already present.
2011 Published by Elsevier Ireland Ltd.

1. Introduction
Recently a positive relationship between stressful life events and
dementia was reported (Tsolaki et al., 2010). That study included a
large sample size which was assessed in a systematic way. It also
included data from a control group which are missing in previous
studies (Charles et al., 2006).
The possible relationship between life events and dementia could
be explained and mediated through the early development of
depression (Tsolaki et al., 1997). It should be pointed out however
that depression is a different clinical entity from Post Traumatic Stress
Disorder (PTSD), and it is important to distinguish between the
presence of life events and the development of PTSD, which is a quite
different phenomenon with specic clinical features, and rather rare.
It is also important to point out the methodological issues which
are very important in stressful life events research. Two are the major
approaches: The rst one is a self-report assessment of life events
proposed by Rahe, and proved to be reliable and cross-culturally
stable (Rahe, 1969; McDonald et al., 1972; Rahe et al., 1974; Rahe,
1994; Rahe et al., 1999). It registers all events (both positive and
negative) and attributes them an impact score (Life Change Units
LCU). The scoring method has been empirically derived from studies
registering the frequency of such events in the general population, the
impact people attribute to specic events and the temporal
relationship of the presence of such events to the manifestation of
psychosomatic disorders. Events receive an impact score ranging from
Corresponding author at: 6 Odysseos str (parodos Ampelonon), 55535 Pylaia
Thessaloniki, Greece. Tel.: + 30 2310 435702, + 30 6945776935(cell phone).
E-mail address: kfount@med.auth.gr (K.N. Fountoulakis).

123 (death of spouse) to 22 (for minor violations of the law).

However, this method has been criticized by many authors, who
dispute the usefulness of self-report event questionnaires, and stress
the need to exclude events, which might be consequences of illness
although such an approach might lead to biases. Also, the conation of
positive and negative events is controversial (Paykel, 1983, 1997). The
second method is the examiner interview proposed by Paykel and
extensively used in depression research (Paykel et al., 1969, 1971;
Paykel, 1974). The method of interview has obvious advantages over
the self-report method, but has several drawbacks as well. The major
disadvantages lie in the fact that the interview applies judgement
concerning the cause and effect relationship between a specic event
and the illness. Also it applies judgement concerning the mechanism
which is supposedly triggered. Rahe argues that these properties of
the life change events are qualities of the individual rather than
aspects of the environment, and in fact the interview assesses not the
objective impact of the event, but rather the perceived subjective
response from the side of the patient (Rahe, 1978, 1979). Additionally,
the interview with an informant is often unreliable (Paykel, 1997).
The present study reanalyzed the data from the previously published
study (Tsolaki et al., 2010), by using the quantitative LCU method and by
excluding life events that could possibly be either secondary to, or
constitute the cause of dementia. In this way the present study eliminates
two major sources of bias which were present in the previous publication.
2. Material and methods
The study sample and the methods are reported in detail in the original paper
(Tsolaki et al., 2010). The demented patients group consisted of 1271 patients (500
males, 771 females) diagnosed with dementia according to the DSM-IV criteria. The
control group consisted of 140 (48 males, 92 females) cognitively healthy elderly

0165-1781/$ see front matter 2011 Published by Elsevier Ireland Ltd.

doi:10.1016/j.psychres.2011.05.011

Please cite this article as: Fountoulakis, K.N., et al., Life events and dementia: What is the nature of their relationship? Psychiatry Research
(2011), doi:10.1016/j.psychres.2011.05.011

K.N. Fountoulakis et al. / Psychiatry Research xxx (2011) xxxxxx

subjects. The two groups were age- and gender-matched. The diagnosis was made after
careful medical history, physical examination, laboratory testing, neuropsychological
tests and brain-imaging scans performed by experienced mental health professionals.
All cases of primary depression were excluded. All patients were recruited from the
Memory and Dementia Outpatient Clinic of the 3rd University Department of
Neurology in G. Papanikolaou General Hospital, in Thessaloniki, Greece. The controls
were recruited from a healthy population sample of adult day care centers.
The stressful events were reported by caregivers who were asked, in a standardized
way, if their patient underwent any stressful event in the last year before the onset of
symptoms. A stressful event was dened as a novel and/or unpredictable event, over
which the sufferer must have the feeling of no control. The answer was yes/no. If yes,
the stress factors were reported in detail, and they were classied after qualitative
analysis. For both patients and controls the presence of any event from a list of 13
events (Table 1) was established. Caregivers were asked to dene how long after the
stressful event the clinical symptoms of dementia appeared. Cases reporting changes
earlier than 3 months after the stroke were excluded.
In the current analysis we applied the Life Change Units scoring (LCU) (Rahe, 1994,
1995) in the events reported by patients and controls. The LCU impact scores used
come from the 19941995 scoring norms proposed by Rahe. Because of the big
difference in the size of the two groups (1271 vs. 140) no statistical testing concerning
the LCU means between the two groups was performed.
The biggest problem was to separate dependent from independent life events.
Some of the events in the list are clearly independent (e.g. death of spouse or parents)
and others are clearly dependent (e.g. stroke). However, for some of them their nature
is debatable. Even for those who appear to be denitely independent, there might be
arguments for the presence of a disease effect. For example, illness or even death of
relatives or caregivers might be the consequence of the disease of the index patient,
since it is well known that the caregivers' health is adversely affected, and even
accidents might happen to them at a higher frequency. The authors chose to exclude
them in a step-by-step way and to observe the way the results change. This method will
also give a clue whether these events are indeed dependent or independent.

3. Results
The LCU scores concerning the various life events and the average
score per subject in the two groups after including all events and after
excluding stroke, traumatic brain injury, health problems, nancial and
professional difculties, problems within the family and stressful
situations, retirement and loneliness are shown in Table 1. The data in
this table correspond to the data reported in the original study (Tsolaki
et al., 2010), in the Table 3 of that study with additional data included in

the body of the manuscript. The results shown in Table 1 of the current
paper suggest that demented patients manifest less stressful events
than controls, especially as confounding effects (that is events with a
possible etiopathological relationship to dementia) are removed on a
step-by-step basis. In case all events are included, the two groups have
similar LCU loading. When all the problematic events are removed, the
demented group manifests half LCU loading in comparison to controls.
For both groups the level of LCU load (sum of all events impact score) is
far below the threshold of 100 suggested by Rahe for the induction of
psychosomatic disorders. As the analysis progressed by removing
events in a step-by-step way, the picture stabilized with demented
patients having half the LCU load in comparison to controls.

4. Discussion
The results of the current reanalysis suggest that most life events
reported by demented patients are either secondary or constitute
causal factors in the development of dementia. This is similar to what
is believed concerning depression with the addition of the role social
relationships play in mediating life events (Paykel et al., 1984; Kelly
et al., 2000; Friis et al., 2002; Wildes et al., 2002).
As mentioned one possible mediating factor between life events and
dementia could be the early development of depression (Tsolaki et al.,
1997), but again the relationship between depression and life events is
doubtful (Paykel, 1994; Paykel, 2001a,b; Iacovides et al., 2002). Life
events tend to drop in normal controls as age increases (Salsali and
Silverstone 2003; Silverstone and Salsali 2003; Fountoulakis et al.,
2006), however, the opposite seems to hold true for depressed patients
(Fountoulakis et al., 2006), suggesting that life events in depressive
individuals are rather secondary than primary.
Still, what remains to be claried is whether early adversities and
adulthood stressors are involved in the development of neuropsychiatric disorders at a later stage of life (Paykel, 1976). A history of
childhood abuse per se may be related to increased neuroendocrine
stress reactivity, which is further enhanced when additional trauma is

Table 1
Life events, their LCU scoring and mean LCU loading per subject in the two groups.
Demented patients

Controls

Stressful event

LCU

Demented patients

Total LCU
Controls

No stress reported
Spouse death
Parents' death
Death of son, daughter, grandchild
Death of sibling and other beloved persons
Surgical intervention serious health problems
Illness of spouse, parents, son, daughter, grandparents
Problems within the family, stressful situations
Financial difculties, professional problems
Retirement, loneliness
Change in familiar environment
Road accident
Stroke
Traumatic brain injury
Total
Mean LCU per subject (all events)
Mean LCU per subject (excluding stroke)
Mean LCU per subject (excluding stroke, traumatic brain injury)
Mean LCU per subject (excluding stroke, traumatic brain injury,
health problems)
Mean LCU per subject (excluding stroke, traumatic brain injury,
health problems, nancial and professional difculties)
Mean LCU per subject (excluding stroke, traumatic brain injury,
health problems, nancial and professional difculties,
problems within the family and stressful situations)
Mean LCU per subject (excluding stroke, traumatic brain injury, health
problems, nancial and professional difculties, problems within
the family and stressful situations, retirement and loneliness)

0
123
94
94
94
80
58
51
57
55
42
80
80
80

281
100
24
36
77
228
41
157
43
32
8
17
209
18
1271

22.11
7.87
1.89
2.83
6.06
17.94
3.23
12.35
3.38
2.52
0.63
1.34
16.44
1.42
100.00

63
30
0
0
25
0
34
17
0
0
0
0
0
0
140

45.00
21.43
0.00
0.00
17.86
0.00
24.29
12.14
0.00
0.00
0.00
0.00
0.00
0.00
100.00

0
12,300
2256
3384
7238
18,240
2378
8007
2451
1760
336
1360
16,720
1440
77,870
61.26
48.11
46.97
32.62

0
3690
0
0
2350
0
1972
867
0
0
0
0
0
0
8879
63.42
63.42
63.42
63.42

30.70

63.42

24.40

57.23

23.01

57.23

Please cite this article as: Fountoulakis, K.N., et al., Life events and dementia: What is the nature of their relationship? Psychiatry Research
(2011), doi:10.1016/j.psychres.2011.05.011

K.N. Fountoulakis et al. / Psychiatry Research xxx (2011) xxxxxx

experienced in adulthood (Heim et al., 2002). It has been reported that

adolescent life events predict an increased risk for major depression
diagnosis in early adulthood (Pine et al., 2002) which could be
specically characterized by an overactivity of the hypothalamic
pituitaryadrenal axis and hypercortisolaimia (Fountoulakis et al.,
2004) which could also constitute a familial vulnerability marker even
for the development of dementia (Fountoulakis et al., 2005).
The method utilized in the current study (as well as in the original)
concerning the gathering of data was the interview of a relative/
caregiver or informer, which is of unknown reliability. However it is
doubtful that any alternative to this method exists. The inclusion of
stroke and other events which constitute potential causal factors of
dementia by themselves should be accepted with caution even after
the 3-months interval in the development of dementia symptoms.
Conclusively, the current reanalysis suggests that patients with
dementia do not experience more stressful life events during the
onset of dementia and they do not experience a higher LCU load in
comparison to controls. On the contrary it is highly likely that they
experience fewer events possibly because of limitations in their
activity that the onset of their illness poses.
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Please cite this article as: Fountoulakis, K.N., et al., Life events and dementia: What is the nature of their relationship? Psychiatry Research
(2011), doi:10.1016/j.psychres.2011.05.011