Transcript CLINICAL STRATEGY Ola Junaid Clinical Director Claire Holmes

DEMENTIA AND
DEPRESSION
Ola Junaid
Clinical Director
Mental Health Services Older People
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DEMENTIA
Chronic or progressive brain disorder
Disturbance of multiple higher cortical functions
including memory, thinking, orientation,
comprehension, calculation, learning capacity,
language and judgement.
Deterioration in emotional control, social
behaviour or motivation
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DIAGNOSIS
Cognitive impairment
Impairment in activities of daily living
High index of suspicion when there is a change
in behaviour or performance without a reason
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Standard history
○ Change in behaviour or performance
○ Rule out depression
Cognitive assessment
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6CIT
Clock drawing
MMSE
ACE -R
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6-CIT
Primary care screening tool
6 questions
3 - 4 minutes
Score 0 -28
0 – 7 normal
8 or more significant
Sensitivity 90%
Specificity 100%
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Brooke and Bullock 1999 I J Ger Psychiat
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6 CIT
What year is it?
What month is it?
5 component name and address
About what time is it (within the hour)
Count backwards from 20 to 1
Say the months of the year in reverse
Repeat address phrase.
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Mini mental state examination
10 minutes
Floor and ceiling effects
24 cut off point
Copyright issues beware
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MMSE
Orientation in time and place
Registration
Attention and concentration
Short term recall
Language
Visuospatial skills
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Addenbrooke’s Cognitive
Examination ACE- R
15 – 20 minutes
Attention and concentration
Memory
Fluency
Language
Visuospatial
○ <88 gives 94% sensitivity and 89% specificity for
dementia
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MANAGEMENT
Prevention
○ Healthy lifestyle
○ Reduce cardiovascular risk factors
Non pharmacological
○ Cognitive stimulation
Acetylcholinesterases
Memantine
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Depression and Aging
Normal vs Abnormal
Age related decline in mental well being should
not be seen as inevitable
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Depression in older people is common.
1 in 4 have symptoms requiring treatment
It is often undetected resulting in significant
impact on quality of life, physical health and
mortality.
There is good evidence for the effectiveness of
psychological interventions and antidepressants.
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Depression
Low mood
Loss of interest and enjoyment
Reduced energy leading to increased
fatiguability and diminished activity
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Biological features
Anhedonia
Early morning wakening
Diurnal mood variation
Psychomotor retardation or agitation
Loss of appetite
Weight loss >5%
Loss of libido
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Older people
Non specific symptoms
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Malaise
Tiredness
Insomnia
Pain
Somatic symptoms
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Mild
○ Distress and impaired occupational/social activity
Moderate
○ Significant difficulty in social work or domestic activity
Severe
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Considerable distress or agitation or retardation
Loss of self esteem, feelings of uselessness or guilt
Suicide risk
Psychotic symptoms
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NICE
During the last month, have you often been
bothered by feeling down, depressed or
hopeless?
During the last month, have you often been
bothered by having little interest or pleasure in
doing things?
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STEPS
1 all suspected depression:
○ assessment, support, psychoeducation,
○ active monitoring and referral
2 persistent subthreshold depressive symptoms;
mild to moderate depression
○ low intensity psychological and psychosocial
interventions, medication and referral
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STEP 3
 Persistent subthreshold symptoms or mild to
moderate depression with inadequate response;
moderate and severe depression
○ Medication, high intensity psychological interventions,
combined treatments, collaborative care and referral
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STEP 4
Severe and complex depression; risk to life;
severe self neglect
○ Medication, psychotherapy, ECT, crisis service,
combined treatments multiprofessional and inpatient
care.
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Assessment
History
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Explore symptoms
Identify triggers
Previous history
Maintaining factors drugs alcohol
Review medication
Corroborative information
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Risk assessment
Previous self harm
Current thoughts of self harm
Explore whether any plans have been made
Factors preventing patient from acting on thoughts
or plans
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NICE
Persistent subthreshold depressive symptoms or
mild to moderate depression
individual guided self (CBT based)
computerised CBT
structured group physical activity
programme
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NICE
Do not use antidepressants routinely to treat
persistent subthreshold depressive symptoms or
mild depression. The risk benefit ratio is poor.
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Drugs
A past history of moderate or severe depression
Subthreshold depressive symptoms for over 2
years
Subthreshold symptoms or mild depression that
persists after other interventions.
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Moderate or severe depression
A combination of antidepressant medication and
CBT or Interpersonal Therapy (IPT)
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antidepressants
CHOICE
○ Anticipated adverse effects
○ Potential interactions
○ Persons perception of the efficacy and tolerability of
previous antidepressants
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SSRIs
Increased risk of bleeding
Fluoxetine, fluovoxamine and paroxetine higher
risk of drug interactions
Citalopram or sertraline in chronic physical
health problems
Paroxetine higher discontinuation symptoms
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toxicity
Venlafaxine greater risk of death from overdose
Lofepramine safest of the TCAs in overdose
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