Depression –early sign dementia.pptx (psychiatry)

Depression in geriatric population

1. Depression in elderly –early sign of dementia? Dr Hema Malini Supervisor Dr Teh Ewe Eow

2. Introduction Depression and dementia are common syndromes in older people. Limited studies investigating on depression in people with vascular dementia,Lewy body dementia,or dementia associated with Parkinson disease suggest that depression may be more common in these syndromes than in Alzheimer disease. (Enache et al.,2011). Depression can occur in all forms of dementia but is most common with vascular dementia. ( Alzheimers Society)

3. Epidemiology In hospitalised patients and nursing home residents , prevalence over 40%. (Huang et al.,2011). Depression in mild cognitive impairment, prevalence of 40% in hospital based patients, 16% among community based samples. (Enache et al.,2011) There is some evidence that ,stage of dementia and insight into the diagnosis have little impact on depression rates. (Carpenter et al.,2008).

4. Depression in elderly Depressive symptoms are present in about 15% of all older adult community. (Kaplan & Sadock’s, 2015) A 2013 systematic review and meta analysis of 23 community based cohort studies undertaken to evaluate the risk of incident of dementia in people with late life onset depression. It was found that depression was associated with an increased risk of dementia .( Diniz et al.,2013) Depression in earlier life increases the risk of dementia in later life by 2fold. ( Ownby et al., 2006) A large Danish study has found that the rate of a subsequent diagnosis of dementia was significantly correlated with the number of prior depressive episodes with rate of dementia increasing by 13% with every inpatient admission for depressive episode. ( Kessing,L . V. , A. , P. K. ,2004)

5. Etiology Neurological disease that caused dementia e.g. AD, Parkinson’s, cerebrovascular disease. Medical conditions e.g. hypothyroidism, vitamin deficiencies, congestive cardiac failure. Pharmacological treatment which may induce depressive symptoms e.g. B blockers , CCB, Digoxin, steroids, alcohol withdrawal.

6. Risk factors in developing depression Female Early age onset of dementia Past history of depression or emotional problems Recent losses.

7. Relationship between dementia and depression. History of depression is a risk factor for developing dementia. Particularly if its early in life or is severe. Conversely, incident depression occurring temporally close to the onset of cognitive impairment may represent prodromal symptoms of dementia. A neuropathological mechanism common to both conditions, such as cerebrovascular disease or hippocampal atrophy has been suggested.

8. History Depression Dementia Symptoms develop quickly after onset Symptoms develop slowly after onset and throughout the course of the illness Onset of symptoms dated with accuracy The onset of symptoms is only known within broad limits. Family is aware of problem and that it is severe Family is often unaware that there is a problem and of its severity. Medical help is sought shortly after symptoms begin. Medical help is usually sought a long time after symptoms develop

9. Cognitive symptoms. Depression Dementia Person complains much about cognitive loss Person usually complains little about cognitive loss. Complains about cognitive dysfunction is usually detailed. Complaints about cognitive problems are usually vague. Person emphasizes disability Person conceals disability.

10. Behaviour Depression Dementia Little effort to perform even simple tasks. Struggles to preform tasks. Communicates a strong sense of distress. Often appears unconcerned. Highlights failures. Delights in accomplishments. Loss of social skills early and prominent. Social skills are retained. Change in mood is pervasive. Mood is labile an shallow. Not typical to experience accentuated problems at night. Typical to experience accentuated problems at night.

11. Assessment of depression in dementia Depression in people remained underdiagnosed. Depression may present differently in people with comorbid dementia. Clinical picture often lacks prominent sadness, hopelessness and guilt. Anxiety , psychomotor retardation, loss of energy or appetite, anhedonia, irritability, delusions and hallucinations may be more common.

12. Depression in dementia Unexpected or rapid change in mood ,cognitive deterioration , or increased behavioural symptoms of dementia( disinhibition, agitation, anxiety, or aggression) may be indicators of superimposed depression. Can be less severe May not last long and symptoms may come and go Patient with dementia may be less likely to talk about or attempt suicide.

13. National Institute of Mental Health Guidelines for diagnosing depression in people with Alzheimer’s. Although criteria are similar to general diagnostic standards for major depression, they reduce emphasis on verbal expression and include irritability and social isolation.

14. Diagnostic tool

15. NIMH- dAD criteria identify a greater proportion of AD as depressed than other established tools. The baseline frequency of depression using NIMH- d AD criteria (44%) higher than using DSM 4, CSDD or GDS .( Edmond et al., 2010)

16. CSDD

17. Consequences of depression in dementia Increased burden on patients and caregivers. Increased caregiver depression. Exacerbation of cognitive and functional decline. More dementia related behavioural disturbance. Poor outcomes from other medical or surgical interventions Earlier admission to nursing homes Increased mortality

18. SUICIDE IN DEMENTIA Suicidal ideation was self reported by 4% of patients with dementia and associated with comorbid depressive symptoms,especially in AD. 10 year retrospective analysis reported that 7.4% of all elderly inpatients diagnosed with AD were admitted after suicide attempts. (Maria M. D., Aurel P., et al.,2015)

19. Suicide in dementia Increased risk in diagnosis of AD during early stage due to depression and altered decision making in related to frontal brain lesions. ( Ismael et al.,2018) It is reported that early stage of dementia is a risk factor for suicide in later life. ( Seyfried et al., 2011) The risk of suicide declines at higher stages of deterioration in executive function and increased supervision. A study among older people in South Korea found that 40% of those who wanted to suicide had depressive disorders and 22% had dementia. ( Chiu et al., 2003)

20. Predictors of suicide in patients with dementia A retrospective cohort study revealed that the increased risk was associated with depression,history of psychiatric admission, and lower in nursing home admission. Severity of medical comorbidity did not affect risk of suicide. Majority of suicides occurred in those who were newly diagnosed with dementia. ( Seyfried et al., 2011)

21. Potential predictors for suicide with Dementia Independent variable Odds ratio (95% CI) Male sex 2.49 (0.79-7.83) White race 1.49 (1.14-1.95) Depression 2.04 (1.45-2.85) Inpatient psychiatric stay 2.31 (1.54-3.46) Antidepressant prescription 1.98 (1.48-2.65) Antianxiety prescription 2.11 (1.57-2.84)

22. Suicide risk assessment Columbia suicide severity rating scale. Geriatric suicide ideation scale. Beck scale for suicide ideation. Clinical Global Impression-severity of suicidality (CGI-SS)

23. Disclosure of diagnosis Simple. Emphasis on slow progression Quality of life can be maintained Symptomatic treatments are available Realistic hope should be provided Early counselling,commitment

24. Prevention of dementia Physical health Keeping cardiovascular risk in control Lifestyle changes-healthy diet,exercise Targeting sugar in food, smoking and alcohol consumption. It has been estimated that if it was possible to delay the onset of dementia by as little as 1 year, that would reduce the prevalence of dementia by 12 million fewer cases worldwide in 2050.( Paillard -Borg et al., 2009)

25. Screening investigations FBC Electrolyte screen Renal function Liver function Thyroid function FBS/FLP Cerebral imaging Vit B

26. Management Bio- psyco -social

27. Nice guidelines For people living with mild to moderate dementia who have mild to moderate depression and/or anxiety,consider psychological treatments. Do not routinely offer antidepressants to manage mild to moderate depression in people with mild to moderate dementia,unless indicated for a pre-existing severe mental health problems.

28. Pharmacotherapy Earlier trials found antidepressants beneficial. SSRI may exert some degree of protection against the negative effects of depression on cognition when people are taking cholinesterase inhibitors. ( Rozzini et al., 2010) Recent studies have failed to demonstrate the effectiveness of SSRI, NaSSA in treating depression in AD. (Banerjee et al., 2011) One study group considered early antidepressant treatment for patient with past history of response to antidepressant, present or past suicide risk and high distress level. ( Macfarlane et al., 2012)

29. There is little evidence that any class of antidepressants is superior. (Nelson et al.,2011) SSRI,NASSA,SNRI are thought to be associated with fewer side effects and drug interactions compared to TCA. (Coupland C. , Dhiman P , Morriss R, et al., 2011) The decision to commence should include consideration of adverse effects and patient profile. Some evidence for lithium augmentation for treatment resistant depression in dementia .(Cooper C., Katona C., Lyketsos K, et al., 2011).

30. Non pharmacological CBT and interpersonal therapies for mild dementia. ( Payman et al., 2011) Validation therapy,using empathic activities such as handholding and singing has demonstrated effectiveness ( O’Connor DW., et al., 2009). Music and recreational therapy demonstrated moderate effect sizes for depression in dementia,including severe dementia. Regular physical activity has been shown to improve mood,including in people with dementia.

31. ECT Cognitive impairment has conventionally been viewed as a relative contraindication,largely due to cognitive side effects. However recent review of ECT in people with depression an dementia suggested that it can be effective and that cognitive side effects are not universal. ( Oudman E.,2012)

32. Practise pearls Consider early dementia in older people who present with new onset depression. Regularly assess patient with dementia for depression e.g 6 monthly especially if in residential care. Exclude physical illness or medications as a cause for depressed mood. Antidepressants may be helpful in moderate to severe depression,start low,go slow,monitor therapeutic effects and side effects. Incorporate psychological and social interventions. Involve carer in management ,also address carer burden.

33. Reference Enache D,Winblad B , Aarsland D. Depression in dementia: epidiomoly,mechanisms and treatment. Psychiaty 2011; 24: 461-472 Winblad B. Palmer K,Kivipelto M, et al.Mild cognitive impairment-beyond controversies,towards consensus;report of the International Working Group on Mild Cognitive Impairment.J Intern Med 2004;256;240-246 Huang CQ,Wang ZR ,Li YH,et al.Cognitive function and risk of depression in old age;a meta analysis of published literature. Int Psychogeriatric 2011;23;513-525.

34. Chiu HFK, Y Takahashi ,GH Suh (2003) Elderly suicide prevention in East Asia.International Journal of Geriatric Psychiatry 18(11);973-976 Draper B., Crescida M. .C. M.,Henry B. (1998) Suicidal ideation and the wish to die indementia patients;the role of depression.Age and aging 27(4);503-573 Seyfried , Lisa S (2011) Predictors of suicide in patients with dementia.Alzheimers disease;the journal of Alzheimers association 7(6);567-573

35. Ismael C., Sophie N., et al., (2018) A Complex relationship between suicide, dementia and amyloid;a narrative review.Front neuroscience;371 Maria M. D., Aurel P., et al., 2015,The role of depression in suicidal ideation of dementia patients;Alzheimers and dementia. Kaplan & Sadocks Book of psychiatry,2015. Medscape Reference Alzheimers and dementia website