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. Author manuscript; available in PMC: 2025 May 1.
Published in final edited form as: Exp Aging Res. 2023 Mar 29;50(3):360–375. doi: 10.1080/0361073X.2023.2195295

Depressive Symptoms are Associated With Decline Over Time in Verbal Fluency Performance in Female but not Male Community-Dwelling Older Adults

Jessica S Wasserman 1, Roee Holtzer 1,2
PMCID: PMC10539484  NIHMSID: NIHMS1885718  PMID: 36989442

Abstract

Objective:

The current study was designed to examine associations between depressive symptoms and longitudinal declines in category and letter fluency performance in a gender-stratified sample of older adults.

Method:

Participants were community-residing older adults (females: n=289; males: n=233) followed annually (2011–2018) as part of a cohort study conducted at Albert Einstein College of Medicine in New York. Depressive symptoms were assessed using the Geriatric Depression Scale (GDS). Standard forms assessed category and letter fluency performance. Participants were dementia-free at study enrollment.

Results:

The presence of baseline depressive symptoms suggestive of subclinical depression was associated with worse longitudinal decline in category fluency performance in female but not male participants. These associations remained significant when excluding participants with prevalent and incident mild cognitive impairment and incident dementia. Irrespective of gender, letter fluency performance did not decline over time and was not influenced by the presence of depressive symptoms.

Discussion:

The present study’s results can aid in identification of older adults who may be at greater risk for cognitive decline, and add to the limited literature examining the influence of gender on longitudinal associations between depressive symptoms and verbal fluency performance.

Keywords: depressive symptoms, verbal fluency, gender, aging, cognition

Gender and Depression in Older Adults

Late-life depression is common in older adults, with prevalence rates of clinically significant depressive symptoms among older adults ranging from 8–16% (Taylor, 2014). Subclinical depressive symptoms are also common among older adults; research in older adult community samples has shown that prevalence of subclinical depression symptoms range from 8.8% to 21.3% (Chen et al., 2007; Schoevers et al., 2006). Late-life depression, including clinically significant and subclinical depression, is associated with a variety of negative outcomes, including decreased quality of life (Chachamovich et al., 2008), increased risk for a decline in functional status (Stuck et al., 1999), and worse cognitive performance and worse cognitive decline (Dotson et al., 2008).

Whereas during adolescent years through approximately age 55, the diagnosis and symptoms of depression are more common in females compared to males (Essau et al., 2010; Kessler et al., 1993) results are mixed in older adults (Anstey et al., 2007; Forlani et al., 2014; Girgus et al., 2017; Girgus & Yang, 2015; Li et al., 2011; Regan et al., 2013; Trollor et al., 2007). Furthermore, research examining factors proposed to explain gender-related variability in the presence and symptomatology of depression among older adults, including being widowed (Glei et al., 2013), living alone (Oh et al., 2014), poorer health (Noh et al., 2016), having dementia (Lee et al., 2017), financial strain (Glei et al., 2013), and burdens of caregiving (Pinquart & Sorensen, 2006), yielded inconsistent results.

Verbal Fluency in Older Adults

Performance on measures of category and letter fluency, which are commonly utilized in clinical and research settings (Henry et al., 2004), declines in aging (Harada et al., 2013). This decline in performance is due, in part, to age-related slowing in processing speed (Salthouse, 1996). Furthermore, among healthy older adults without cognitive impairment, performance is worse on category fluency compared to letter fluency (Brickman et al., 2005; Clark et al., 2009). Kavé and Mashal (2012) have proposed that the Transmission Deficit Hypothesis might explain this finding. This hypothesis posits that older adults have weakened associations between semantic representations and phonological representations (Burke et al., 1991; Burke & Shafto, 2004). Letter fluency requires individuals to produce words using only phonological representations, whereas category fluency requires individuals to produce words using both phonological representations and semantic representations (Kavé & Mashal, 2012). Hence, the increased demands imposed on the semantic system in category fluency might explain its greater sensitivity to age-related cognitive decline compared to letter fluency.

Older adults with Alzheimer’s disease perform worse than healthy older adults on verbal fluency tasks, particularly on category fluency tasks (Clark et al., 2009; Martin & Fedio, 1983; Tröster et al., 1989). Further, research has shown that individuals with mild cognitive impairment (MCI) and Alzheimer’s disease perform worse on category fluency tasks as compared to letter fluency tasks (Clark et al., 2009; Henry et al., 2004; Murphy et al., 2006). Clark et al. (2009) also demonstrated that, in healthy older adults and older adults with preclinical Alzheimer’s disease, category fluency performance declined faster than letter fluency performance over longitudinal follow-up. Thus, category fluency appears to be more susceptible to decline than letter fluency performance in healthy older adults and in individuals with neurodegenerative disease. As such, category fluency performance has been suggested to be a useful indicator to differentiate healthy controls from adults with MCI and Alzheimer’s disease (Duff Canning et al., 2004; Monsch et al., 1992).

Depressive Symptoms and Verbal Fluency Performance

Results regarding the association between depressive symptoms and verbal fluency performance in community-dwelling older adults have been mixed. In cross-sectional studies, greater levels of depressive symptoms were associated with worse performance on both category fluency and letter fluency (Auriacombe et al., 2001; Yochim et al., 2013), only on letter fluency (Dotson et al., 2008; Ravdin et al., 2003), or on neither measure (Beaudreau & O’Hara, 2009; Bunce et al., 2012). Longitudinal studies also show mixed results. Gkotzamanis et al. (2021) found that greater levels of depressive symptoms were associated with longitudinal decline in category fluency performance. Additionally, Yochim et al. (2006) found that greater levels of depressive symptoms were associated with worse verbal fluency performance at three months and six months after baseline in older adults treated in an inpatient medical rehabilitation setting. In contrast to these findings, Bunce et al. (2012), Burhanullah et al. (2020), and Dotson et al. (2008) did not find longitudinal associations between depressive symptoms and verbal fluency performance in healthy community-dwelling older adults.

Gender Differences in Verbal Fluency Performance

In cross-sectional studies, McCarrey et al. (2016) reported that females performed better on both category fluency and letter fluency as compared to males; Auriacombe et al. (2001) and Zhang et al. (2017) found that females performed better on category but not letter fluency as compared to males. In contrast, Munro et al. (2012) found that males demonstrated superior performance on letter fluency than females but gender differences on category fluency performance were insignificant. Finally, Elosúa et al. (2021) and Esteves et al. (2015) observed that gender was not associated with letter or category fluency performance. Few longitudinal studies have examined gender differences in changes in verbal fluency performance over time. Of these few studies, McCarrey et al. (2016) did not find gender differences in changes in verbal fluency performance over time, while Zaninotto et al. (2018) found that depressive symptoms predicted faster decline in category fluency performance for males only.

Present Study

The present study was designed to address an important gap in the literature concerning the relationships between gender, depressive symptoms, and longitudinal declines in category and letter fluency among community-residing older adults. Specifically, we aimed to determine whether the impact of baseline levels of depressive symptoms on longitudinal changes in category and letter fluency performance was different in women as compared to men ages 65 years or older. We further evaluated whether the length of follow-up, presence of mild cognitive impairments at baseline, development of mild cognitive impairments during follow-up, and development of dementia during follow-up influenced the associations between depressive symptoms and longitudinal changes in verbal fluency performance.

Method

Participants

Community-dwelling older adults aged 65 years or older participated in a longitudinal cohort study, Central Control of Mobility in Aging (CCMA), which examined cognitive predictors of mobility and decline in aging. Study participants (N = 522) were recruited from Westchester County, NY via a letter sent to their home and by a telephone call inviting them to participate in the study. A structured telephone interview was administered to screen potential participants for eligibility. Participants were excluded if they had difficulty understanding or speaking English, an inability to ambulate independently, a positive screen for possible dementia, a significant loss of vision and/or hearing, current or a history of neurological or psychiatric disorders, recent or anticipated medical procedures that could affect mobility, and receiving hemodialysis. Eligible study participants were scheduled for two in-person visits that consisted of neuropsychological, cognitive, psychological, neurological, and mobility assessments. Participants provided written informed consent for the study protocol, approved by the Albert Einstein College of Medicine Institutional Review Board, at their first clinic visit. Participants’ baseline visits took place between June 2011 and October 2017. Participants completed yearly follow-up visits for up to seven years. Participants’ cognitive status (normal, MCI, or dementia) was evaluated using diagnostic case conference procedures as previously described (Holtzer et al., 2008a). See Holtzer et al. (2014) for a more detailed description of study procedures.

Measures

Depressive Symptoms

Depressive symptoms were measured at baseline using the Geriatric Depression Scale (GDS; Yesavage et al., 1983). The GDS is a 30-item self-report measure that asks respondents whether they experienced specific depressive symptoms in the past week. Respondents provide “yes” or “no” responses to each statement. Scores range from 0–30 and each item is worth 1 point. The GDS has been shown to be a reliable and valid measure of depression in older adult populations and is commonly used in research and clinical settings to screen for depression (Areán & Ayalon, 2005; Krishnamoorthy et al., 2020; Yesavage et al., 1983). Brink et al. (1982) conducted sensitivity and specificity analyses on the GDS and found that, in a sample of older adults, a score of 11 resulted in a 84% sensitivity rate and a 95% specificity rate of depression. Based on these results, Brink et al. (1982) recommended cutoff points, such that total scores of 0–10 indicate that the respondent does not have depression, whereas scores greater than or equal to 11 are considered a possible indication of depression. These cut-off scores have been utilized in prior research (Arfken et al., 1994; Koizumi et al., 2005; Wang et al., 2022).

Verbal Fluency

Verbal fluency performance was measured annually. The Controlled Oral Word Association Test (COWAT; Spreen & Benton, 1977) was used to examine category and letter fluency. The COWAT has commonly been used to assess verbal fluency in samples of healthy community-dwelling older adults (Axelrod & Henry, 1992). The letter fluency task instructed participants to rapidly generate words that begin with a specific letter (F, A, and S) in 60 s. Participants were asked not to give responses of proper nouns or multiple responses with the same root and different suffixes; these were denoted as incorrect responses. Repetitions and perseverations were additionally denoted as incorrect responses. Participants were also given a category fluency task, and were instructed to rapidly name items that belonged to the same category in 60 s. The categories consisted of fruits, vegetables, and animals. Repetitions and perseverations were denoted as incorrect responses. Scores across the three trials in the letter fluency task and scores across the three trials in the category fluency task were separately summed for each participant. The total scores for category and letter fluency were converted into averaged z-scores based on the sample distribution.

Covariates

Covariates included age, years of education, Wide Range Achievement Test - Third Edition (WRAT-3; Wilkinson, 1993) and a Global Health Score (GHS; Holtzer, et al., 2006). The WRAT-3 was used as a measure of estimated premorbid functioning. The GHS ranges from 0–10 and was used to adjust for health comorbidities, including arthritis, hypertension, stroke, and Parkinson’s disease.

Statistical Analysis

Data were inspected visually to examine the distributions of the variables. Descriptive statistics were calculated for demographic characteristics and baseline variables, including depressive symptoms and performances on category and letter fluency. Depressive symptoms were measured using the total GDS score. As our sample was relatively healthy, we expected most GDS scores to be within the normal range. Based on the positively skewed distribution of the scores that demonstrated that depressive symptoms were low across the sample, depressive symptoms were examined as a dichotomized variable, using Brink et al. (1982)’s cut-off points. As such, individuals whose GDS score was 10 or less were in the “no depression” group, whereas individuals whose GDS score was 11 or greater were in the “possible depression” group. As the distributions for category and letter fluency scores were normally distributed, category and letter fluency performance were examined as continuous variables. Category and letter fluency performance were examined as z-scores based on the sample distribution.

Linear mixed effects models, stratified by gender, were utilized to examine whether baseline depressive symptoms predicted decline in performance on category and letter fluency over time. Linear mixed effects models were selected for their strengths in analysis of non-independent data and ability to handle missing data (Brauer & Curtin, 2017). To analyze the moderating effect of the predictor variable on cognitive decline, two-way interactions between the predictor and time were examined. The predictor and covariates were entered as fixed effects, and subject and time were entered as random effects. Time was a repeated random effect and was defined by years of data collection (years one to five). Primary analyses were restricted to years one through five to account for attrition in the last two years of follow-up that could have biased the results. The moderating effects of depressive symptoms on longitudinal changes in verbal fluency were examined via two-way interactions of baseline GDS scores and time. In all models, baseline GDS score was used as the two-level predictor variable and category and letter fluency performance served as the outcome variables. Models were first run unadjusted then adjusted for covariates. SPSS Version 27 was utilized to run analyses.

Several supplementary sensitivity analyses were run to examine the effects of confounders on study outcomes. First, we examined whether extending length of follow-up to include years with significant attrition impacted the relationship between depressive symptoms and change in verbal fluency performance. Additional sensitivity analyses were run excluding participants with prevalent MCI (i.e., MCI at baseline), incident MCI (i.e., MCI developed at follow-up), and incident dementia (i.e., dementia developed at follow-up). All supplementary gender-stratified models were run first unadjusted then adjusted for covariates.

Results

Participant Characteristics

Of those participants screened for eligibility, 591 participants were deemed eligible and participated in the CCMA study. Sixty participants were excluded due to missing baseline demographic variables and cognitive scores and nine were excluded due to being assigned a case consensus diagnosis of dementia at baseline. Thus, data from 522 participants were utilized in data analyses. As can be seen in Table 1, the sample of 522 participants had a mean age of 75.96 (SD = 6.46) and had a mean of 14.60 (SD = 2.92) years of education. Of the 522 participants, 80.30% were Caucasian and 55.40% were female. Gender and ethnicity were collected via participant self-report. Participants reported minimal levels of depression, reflected by a GDS mean of 4.72 (SD = 3.96), and were relatively healthy, demonstrated by a GHS mean of 1.63 (SD = 1.08). Participants demonstrated estimated premorbid functioning within the average range on the WRAT-3 (M = 106.88, SD = 0.44). Participants demonstrated average baseline performance on category fluency (z-score = 0.21, SD = 1.26) and letter fluency (z-score = 0.12, SD = 1.15). See Table 1 for further descriptive statistics of baseline demographic characteristics and variables. Mean length of follow up was 3.64 (SD = 1.74) years. Annual attrition rate for the first five years of follow-up was approximately 14%, and largely due to the conclusion of active data collection, sample size was significantly reduced in the last two years of follow-up.

Table 1.

Baseline Demographic Characteristics, Depressive Symptoms, and Verbal Fluency Scores for Total Sample and for Sample Stratified by Depressive Symptoms and by Gender

Baseline Characteristic Total Sample (N = 522) M(SD) or n(%) No Depression (n = 478) M(SD) or n(%) Possible Depression (n = 44) M(SD) or n(%) p Females (n = 289) M(SD) or n(%) Males (n = 233) M(SD) or n(%) p
Age 75.96 (6.46) 75.94 (6.45) 76.20 (6.63) .755 76.18 (6.36) 75.68 (6.58) .229
Gender -- -- -- .035 -- -- --
 Female 289 (55.40%) 258 (89.27%) 31 (10.73%) -- -- -- --
 Male 233 (44.60%) 220 (94.42%) 13 (5.58%) -- -- -- --
Education 14.60 (2.92) 14.67 (2.93) 13.75 (2.67) .044 14.22 (2.69) 15.06 (3.12) .001
GDS 4.72 (3.96) 3.84 (2.70) 14.23 (2.81) -- 4.96 (4.17) 4.42 (3.67) .250
GHS 1.63 (1.08) 1.59 (1.08) 2.07 (1.02) .005 1.68 (1.08) 1.58 (1.08) .301
WRAT-3 106.88 (0.44) 107.12 (9.84) 104.25 (11.53) .100 106.92 (9.83) 106.82 (10.27) .900
CAT 0.21 (1.26) 0.22 (1.28) 0.15 (1.04) .758 0.39 (1.26) −0.01 (1.24) <.001
LET 0.12 (1.15) 0.15 (1.14) −0.11 (1.27) .157 0.22 (1.16) 0.01 (1.13) .036
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Note. Age represented as years of age; education represented as years of education; GDS = Geriatric Depression Scale; GHS = Global Health Status; WRAT-3 = Wide Range Achievement Test – 3rd Edition; CAT = Category Fluency; LET = Letter Fluency; scores for Category Fluency and Letter Fluency are displayed as z-scores based on the robust norms from Holtzer et al. (2008a); p-values indicate significance values for group comparisons between No Depression and Possible Depression and between Females and Males respectively.

Based on clinical cut-offs (Brink et al., 1982), 478 participants (91.58% of the total sample) were in the “no depression” group and 44 participants (8.42% of the total sample) were in the “possible depression” group. The “no depression” group included 258 females (89.27% of females) and 220 males (94.42% of males), and the “possible depression” group included 31 females (10.73% of females) and 13 males (5.58% of males). The “no depression” and “possible depression” groups significantly differed on gender, years of education, and GHS score. The “no depression” and “possible depression” groups did not significantly differ on other demographic or cognitive variables. As stated previously, of the 522 participants, 289 (55.40% of the total sample) were female and 233 (44.60% of the total sample) were male. Females and males significantly differed on years of education, baseline category fluency performance, and baseline letter fluency performance, with females outperforming males on baseline category and letter fluency performance. There were no gender differences for age, GDS score, GHS score, or WRAT-3 performance.

Impact of Depressive Symptoms on Category Fluency Performance

As can be seen in Table 2, adjusted linear mixed effects models stratified by gender revealed that category fluency performance declined significantly over time in females (estimate = −0.03, p = .026) and males (estimate = −0.04, p = .024). Furthermore, compared to no depression, the presence of possible depression predicted a greater decline in category fluency performance for females (estimate = −0.16, p = .002) but not males (estimate = −0.03, p = .658). In regard to covariates, older age was associated with worse baseline category fluency performance for females (estimate = −0.04, p < .001) and males (estimate = −0.04, p < .001). Better WRAT-3 performance was associated with better baseline category fluency performance for females (estimate = 0.04, p < .001) and males (estimate = 0.02, p = .002). For males only, greater years of education (estimate = 0.05, p = .029) and higher GHS score (estimate = 0.11, p = .040) was associated with better baseline category fluency performance.

Table 2.

Linear Mixed Effects Model: Stratified Adjusted Model Analyzing the Effect of Gender on the Relationship between Depression and Change in Category Fluency Performance Over 5 Years

Variable Estimate 95% CI t p
Males
 Depression −0.15 [−0.73, 0.42] −0.52 .601
 Time −0.04 [−0.07, −0.01] −2.28 .024
 Depression x Time −0.03 [−0.17, 0.11] −0.44 .658
 Age −0.04 [−0.05, −0.02] −4.08 <.001
 Education (years) 0.05 [0.01, 0.10] 2.20 .029
 GHS 0.11 [0.00, 0.22] 2.06 .040
 WRAT −3 0.02 [0.01, 0.04] 3.09 .002
Females
 Depression 0.12 [−0.26, 0.49] 0.62 .537
 Time −0.03 [−0.07, −0.01] −2.25 .026
 Depression x Time −0.16 [−0.25, −0.06] −3.18 .002
 Age −0.04 [−0.06, −0.03] −5.15 <.001
 Education (years) −0.01 [−0.06, 0.03] −0.54 .588
 GHS −0.03 [−0.12, 0.07] −0.58 .562
 WRAT −3 0.04 [0.03, 0.06] 7.07 <.001
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Note. Depression indicates possible depression (reference group) vs. no depression; GHS = Global Health Status; WRAT-3 = Wide Range Achievement Test – 3rd Edition.

Impact of Depressive Symptoms on Letter Fluency Performance

As can be seen in Table 3, adjusted linear mixed effects models stratified by gender that examined the impact of depressive symptoms on change in letter fluency performance over time found that letter fluency performance did not decline significantly over time in females or males. Further, there were no significant associations between depressive symptoms and letter fluency performance; thus the presence of possible depression, as compared to no depression status, did not predict decline in letter fluency performance for females or males. In regard to covariates, better WRAT-3 performance was associated with better baseline letter fluency performance for females (estimate = 0.05, p < .001) and males (estimate = 0.04, p < .001).

Table 3.

Linear Mixed Effects Model: Stratified Adjusted Model Analyzing the Effect of Gender on the Relationship between Depression and Change in Letter Fluency Performance Over 5 Years

Variable Estimate 95% CI t p
Males
 Depression −0.46 [−0.97, 0.05] −1.77 .078
 Time 0.03 [−0.01, 0.06] 1.72 .087
 Depression x Time 0.05 [−0.08, 0.18] 0.75 .452
 Age −0.01 [−0.02, 0.01] −0.94 .346
 Education (years) 0.02 [−0.02, 0.06] 1.03 .303
 GHS 0.02 [−0.08, 0.12] 0.33 .739
 WRAT −3 0.04 [0.03, 0.06] 6.73 <.001
Females
 Depression 0.06 [−0.29, 0.40] 0.31 .755
 Time 0.02 [−0.01, 0.04] 1.28 .202
 Depression x Time −0.03 [−0.11, 0.05] −0.67 .502
 Age −0.01 [−0.02, 0.01] −0.67 .506
 Education (years) −0.01 [−0.05, 0.03] −0.46 .644
 GHS −0.05 [−0.14, 0.04] −1.05 .294
 WRAT −3 0.05 [0.04, 0.06] 7.97 <.001
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Note. Depression indicates possible depression (reference group) vs. no depression; GHS = Global Health Status; WRAT-3 = Wide Range Achievement Test – 3rd Edition.

Supplementary Analyses

Supplementary stratified, adjusted linear mixed effects models were run to examine whether the results remained the same when extending the length of follow-up to seven years and when excluding participants with prevalent and incident MCI and incident dementia. First, we ran analyses with all 522 participants including data from years one to seven to examine whether extending the length of follow-up would impact the relationship between depressive symptoms and verbal fluency performance. We then ran analyses excluding participants with prevalent or incident MCI (n = 141), analyses excluding participants with incident dementia (n = 28), and analyses excluding participants with prevalent or incident MCI or incident dementia (n = 169). We found that for all supplementary analyses, the presence of possible depression as compared to no depression status predicted declines in category fluency performance for females only, such that extending the length of follow-up (estimate = −0.12, p = .008), excluding prevalent and incident MCI cases (estimate = −0.19, p = .005), excluding incident dementia cases (estimate = −0.12, p = .017), and excluding prevalent and incident MCI and incident dementia cases (estimate = −0.20, p = .004), did not change the results. These results are summarized in Supplementary Tables 1–8.

Discussion

Results indicate that, among community-residing older adults, baseline presence of depressive symptoms suggestive of possible, or subclinical, depression was associated with worse decline in category fluency performance during longitudinal follow-up in female but not male participants. Irrespective of gender, letter fluency performance did not decline over time and was not influenced by levels of depressive symptoms. Notably, supplemental analyses demonstrated that the associations between baseline depressive symptoms suggestive of subclinical depression and decline in category fluency performance over time among older women cannot be attributed to possible attrition biases, nor the presence or development of mild cognitive impairments or dementia.

Importantly, the present study elucidated the influence of depressive symptoms on longitudinal changes in category and letter fluency performance in a gender-stratified sample of older adults. As depressive symptoms and verbal fluency are commonly examined in clinical and research settings, the present study’s results can aid clinicians and researchers in identifying individuals who may be at a greater risk of cognitive decline. Further, subclinical depressive symptoms are prevalent among older adults (Chen et al., 2007; Schoevers et al., 2006), yet may not be as easily or quickly detected (Conner et al., 2010). Thus, it is important to examine the impact of depressive symptoms that do not reach clinical thresholds, as we have shown there is a relationship between subclinical depressive symptoms and an important indicator of cognitive decline, namely, category fluency (Duff Canning et al., 2004). Thus, our results shed light on the lesser-understood impact of subclinical depressive symptoms on verbal fluency performance in community-dwelling older adults, and highlights gender differences for this association. Moreover, although the relationship between depression and dementia remains unclear, research has posited that depression may be a risk factor for developing Alzheimer’s disease (Cantón-Habas et al., 2020; Ownby et al., 2006), and that depression may be a prodrome to dementia (Mirza et al., 2016). Thus, it is imperative to address modifiable risk factors, such as depressive symptoms, earlier in the aging process to reduce the potential risk of cognitive decline (Gkotzamanis et al., 2021).

Consistent with research demonstrating that healthy older adults tend to perform worse on category fluency as compared to letter fluency (Brickman et al., 2005; Clark et al., 2009), we observed that category fluency performance declined over time in females and males, whereas there was no change in letter fluency performance over time for females or males. Our findings are also congruent with research that demonstrated longitudinal associations between depressive symptoms and change in category fluency performance over time (Gkotzamanis et al., 2021; Yochim et al., 2006; Zaninotto et al., 2018). In contrast, Bunce et al. (2012), Burhanullah et al. (2020), and Dotson et al. (2008) did not find longitudinal associations between depressive symptoms and verbal fluency performance. Mixed evidence may, in part, be attributed to methodological differences between studies, including differing sample sizes, demographic characteristics, and measures of depressive symptoms and verbal fluency.

Research has demonstrated mixed evidence for gender differences in baseline verbal fluency performance (Auriacombe et al., 2001; Elosúa et al., 2021; Esteves et al., 2015; McCarrey et al., 2016; Munro et al., 2012; Zhang et al., 2017) and change in verbal fluency performance over time (McCarrey et al., 2016; Zaninotto et al., 2018). Notably, Zaninotto et al. (2018) found that, for males only, depressive symptoms were predictive of faster decline in category fluency performance over time. In contrast to Zaninotto et al. (2018)’s findings, we observed that baseline presence of depressive symptoms suggestive of subclinical depression was associated with worse decline in category fluency performance for females only. It is possible that methodological differences between our study and Zaninotto et al. (2018)’s study, including differences in participant age, depression measures, and number of categories in the category fluency task, account for the discrepancy regarding the impact of depressive symptoms on the change in verbal fluency performance over time in female and male participants. Notably, although studies examining gender differences in depression in older adults have shown mixed results (Anstey et al., 2007; Forlani et al., 2014; Girgus et al., 2017; Li et al., 2011; Regan et al., 2013; Trollor et al., 2007), of studies that did find a gender difference, authors consistently found that females have more depressive symptoms or a greater number of depressive diagnoses as compared to males (Anstey et al., 2007; Girgus et al., 2017; Regan et al., 2013; Trollor et al., 2007); this is in line with the present study’s findings.

Regarding covariates, better WRAT-3 performance was associated with better baseline category fluency performance and letter fluency performance for females and males. Research has shown that WRAT-3 performance is correlated to category fluency and letter fluency performance in older adults (Manly et al., 2004). Further, older age was associated with worse baseline category fluency performance, but not baseline letter fluency performance, in males and females. An association between older age and decline in verbal fluency performance has been reported in the literature (Harada et al., 2013; Singh-Manoux et al., 2012). Further, for males only, greater number of years of education was associated with better baseline category fluency performance, but not baseline letter fluency performance. Higher education has been shown to be associated with superior verbal fluency performance in previous research (e.g., Bolla et al., 1998).

Strengths and Limitations

Strengths of the present study include the use of a longitudinal design with a relatively long period of follow-up in a larger sample of community-dwelling older adults. Robust analyses were utilized to detect change over time in verbal fluency performance and examine the impact of gender and depressive symptoms on change in verbal fluency performance. The observation that results held when extending the length of follow up and excluding participants with prevalent and incident MCI and incident dementia speaks to the strength of the findings. Additionally, adjusting for possible confounders and stratifying the analyses by gender allowed us to specifically assess how depressive symptoms impacted change in verbal fluency performance in female and male participants. Moreover, we were able to adequately assess participants’ cognitive decline over time, as sample-based z-scores for each follow up visit were created by taking baseline fluency performance into account.

Limitations: as expected, there were more female than male participants in this community-based sample of older adults. Group sizes of the “no depression” and “possible depression” groups were disproportionate and the number of females in the “possible depression” group was greater than the number of males. The latter finding is in line with research suggesting that older women may be more likely to experience worse or more depressive symptoms than older men (Anstey et al., 2007; Girgus et al., 2017; Regan et al., 2013; Trollor et al., 2007). It is possible that the lack of a significant association between depression and verbal fluency performance among males in the current study may be attributed, at least in part, to the small number of males in the “possible depression” group, thus reducing the power needed to demonstrate a significant association. Study eligibility criteria excluded individuals with a diagnosis of depression. It is possible that the relationship between depressive symptoms and decline in verbal fluency performance would be stronger in a sample that included individuals with more severe depression. Further, our sample was primarily Caucasian and recruited from a specific geographic area. Research has shown that conceptualization and attribution of symptoms of depression differ across cultures (Lawrence et al., 2006). Thus, the generalizability of our results to more diverse samples should be examined in future research. Although the GDS is a well-validated self-report measure, structured clinical assessments to confirm participants’ self-reported depressive symptoms were not available. Finally, participants may have experienced a practice effect from repeated annual assessments, which may have masked a decline that otherwise may have been observed (Abner et al., 2012).

Conclusions

In summary, the present study found an important relationship between the presence of subclinical depressive symptoms and worse decline in category fluency performance in female but not male participants. Irrespective of gender, participants did not demonstrate decline in letter fluency performance, nor was letter fluency performance associated with depressive symptoms. The results remained when accounting for multiple covariates and potential confounders, including participants who developed MCI and dementia during follow-up.

Supplementary Material

Supp 1

Acknowledgements

This work was supported by the National Institute on Aging under Grants R01AG036921 and R01AG044007.

Footnotes

Disclosure of Interest

The authors report there are no competing interests to declare.

References

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