Transcript IS IT DEPRESSION, IS IT DEMENTIA OR BOTH?

Wicking Dementia Research and Education Centre
IS IT DEPRESSION, IS IT
DEMENTIA OR BOTH?
Dr Joanna Bakas
Consultant Psychiatrist
Dr Kate-Ellen Elliott
Clinical Psychologist
Wicking Dementia Research and Education Centre
What is dementia?
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There are many different causes
It is a syndrome
Acquired and chronic
In most cases irreversible
A decline in intellectual capabilities
There has to be a social decline with failure to cope with an
independent life
• Often progressive
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What is dementia (2)
• Changes in ability to
• generate coherent speech or understand spoken or written language,
• recognise or identify objects,
• execute motor activities,
• think abstractly, make sound judgments, and plan and carry out complex
tasks
But
• Over 100 subtypes have been defined – each with different course,
subtle variation in pattern of expression and neuropathology
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What is depression?
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Not talking about normal sadness
“Major Depressive Disorder”
At least of 2 weeks duration
Changes in appetite and weight
Sleep disturbance – classically early morning wakening
Amotivation
Loss of pleasure or interest in life activities
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What is depression (2)
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Lack of energy
Feelings of guilt, being a burden
Problems with attention and concentration
Recurring thoughts of death and suicide
Patients often describe a difference to normal unhappiness
If becomes severe can develop mood congruent delusions or
hallucinations
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Symptoms in common
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Amotivation
Cognitive changes
Worry about memory!
Difficulty making decisions and problem solving
Anxiety and agitation
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Both occur due to changes in the brain
Dementia
Depression
• Changes in brain chemistry – Serotonin
– Norepinephrine
– Dopamine
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Chronic Course
• Depression
• Recovery expected from mild-moderate
• BUT incomplete recovery and relapse are common
• Longitudinal study conducted in Australia, persons hospitalised for
depression experienced an average of three episodes over a 25-year
period.
• Dementia
• Mostly progressive
• Mean duration for most common forms of dementia, from diagnosis
to death, is around 7-10 years.
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WHY DISCUSS TOGETHER?
• Can be confused especially in very early dementia
• People often have both in very early dementia and
depression can be treated leading to improved quality of
life and functioning
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WHY DISCUSS AT ALL?
• Ageing population & age related disease
• Dementia is a major public health priority
• Worldwide one new case every four seconds & will treble
by 2050
• 3rd leading cause of mortality in Australia
• leading cause of disability for Australians 65 years +
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In 2011, 298,000 Australians had dementia
• Most were women (62%)
• aged 75 years + (74%)
• living in the community (70%)
• 65 years + almost 1 in 10 had dementia
• 85 years + 3 in 10 had dementia
• Younger onset
= 23,900 Australians under the age of 65 years
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WHY DISCUSS AT ALL?
• People with dementia have an increased risk of depression compared with
people without dementia
• The prevalence of depression in dementias has been reported to be between
9 and 68%
• Depression in dementia is associated with
• increased disability,
• more functional and behavioural problems,
• greater stress to carers,
• and increased mortality
• BUT often remains under-diagnosed, untreated or mismanaged.
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Depression in older adults
Sub-clinical depression (some symptoms of depression but not all) is common
• 10-15% of older adults living in the community,
• 30% of older adults living in residential aged care facilities (RACFs)
• For those living in RACFs younger age and high functional disability
significantly associated with ‘clinical depression’
• 15-50% in hospital
• Sub-clinical depression is higher amongst oldest old
• 5.6% at 70 years and 13% at 85 years
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WHY DISCUSS AT ALL?
High rate of completed suicide in elderly
• Men - in 2011
– males 85+ 32.1 per 100,000 vs
– males in general 15.3 per 100,000
• Women
– female 85+ 7.8 per 100,000 vs
– females in general 4.8 per 100,000
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IMPORTANCE OF CAREFUL ASSESSMENT
• TREATMENT FOR THINGS WE CAN TREAT e.g.
delirium, medical illnesses, side effects to
medication, rare reversible dementias and
DEPRESSION
• Importance of careful assessment and reassessment
– not just cross-sectional
• Planning
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MANAGEMENT PRINCIPALS
• Multimodal
• Biopsychosocial approach
• Importance of careful assessment so an
individualised treatment plan can be made
• Reassessment as things can change
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DEPRESSION TREATMENT
• All the above relevant
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Psychological Treatments For Depression
• Most commonly adopted and highly effective
• Cognitive Behavioural Therapy (10-20 sessions)
• Underlying basis – individual’s feelings and behaviour are largely
determined by the way s/he structures or views the world.
• Focuses on the link between cognition (our thoughts) and our
behaviour (our actions).
• Identify and change the behaviours and thinking patterns that cause
and maintain depression.
• Examine belief systems
• Activities to test the validity of the belief system and associated
thoughts.
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Psychological Treatments For Depression
• Most commonly adopted and highly effective
• Interpersonal Psychotherapy (10-20 sessions tapered - weekly,
fortnightly, bimonthly)
• Focuses on problems in personal relationships, and on building skills to
deal with these problems
• Focuses on changes in a person’s social roles, grief and loss (e.g.
marriage, divorce).
• It is different from other types of therapy for depression because it
focuses more on personal relationships than what is going on in the
person’s mind (e.g. thoughts and feelings).
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Psychological Treatments For Depression
• Some evidence to support
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Solution-Focused Brief Therapy
Dialectical Behaviour Therapy
Emotion Focused Therapy
Psychoeducation
• Small amount of evidence to support
• Mindfulness Based Cognitive Therapy
• Acceptance and Commitment Therapy
• Best results occur when treatment is tailored to individual needs and
relapse prevention is addressed
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Social Issues/ Factors
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Housing
Income / Employment
Family problems
Support network - relationships – quality over
quantity
• Education
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Biological Treatments
• Mild to moderate depression often responds well to
psychosocial approaches and does not require biological
therapy
• Moderate to severe spectrum usually does
• More severe depression when people not eating and
drinking adequately , are suicidal or have psychotic
symptoms need urgent psychiatric assessment and
biological treatments
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What are biological treatments?
• Antidepressants – usual treatment
• Antipsychotic medications (if psychotic symptoms are
present or very severe agitation)
• ECT (usually for life threatening situations or when other
things have not worked)
• Beyond Blue website has very good information
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EARLY DEMENTIA
Psychosocial Treatments
• Person-Centered Care
• Cognitive Behavioural Therapy
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Psychoeducation about the disease and symptoms
Collaborative approach – set goals
Changes in roles and relationships
Dealing with stigma
Reduce symptoms of depression and anxiety
• Family-Based Therapy effective when family conflict present
• Consideration of Cognitive Stimulation/Rehabilitation Therapy
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EARLY DEMENTIA
Psychosocial Treatments Continued…
• Caregiver focused therapy
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to empower carer to seek support, using day respite,
emotional support to address adjustment issues to new role and dealing with
loss,
• education about the disease and caregiving strategies – how to recognise
indicators and triggers of unwanted behaviours.
Planning
- Writing will, Enduring Power of Attorney, Enduring Guardianship with wishes
expressed for future care
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Cholinesterase Inhibitors
• Donepezil, galantamine and rivastigmine
• Modest improvements in cognition and function in
most probably around 30% or people
• A rapid symptomatic deterioration can occur when
discontinued
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NMDA Receptor Antagonist
• Memantine
• N-methyl-D-aspartate antagonist
• In moderate to severe dementia has shown a reduction in
decline in a 28 week trial
• A 6 month trial showed benefit in combination with donepezil
in cognition and activities of daily living
• NB can cause increased confusion in some patients
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MODERATE - SEVERE DEMENTIA
Psychosocial Treatments
• Person-Centered Care
• CBT – more focused on behaviourally based strategies
• Behavioural reinforcement strategies
• Progressive Muscle Relaxation
• Reviewing antecedents and consequences of psychiatric and
behavioural symptoms (assessment is key)
• Alter environment, use signs and cues e.g., brightly coloured toilet
seats to help with incontinence
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MODERATE - SERVERE DEMENTIA
Psychosocial Treatments continued…
• Validation therapy
• Reminiscence therapy
• Montessori based approaches
• Exercise
• Music therapy
• Art therapy
• Massage and touch
• Animal assisted therapy
• Can help reduce anxiety and agitation in short-term, but limited rigorous
studies. No harm or severe side effects found.
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MODERATE - SERVERE DEMENTIA
Psychosocial Treatments continued…
• Caregiver focused therapy
• education about care strategies e.g., laying out clothes to
wear to avoid confusing choices
• dealing with grief and loss, adjustment to changes in
relationship and role (may be associated with person with
dementia moving into a nursing home)
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Biological Treatments
• Problematic and not very effective
• First step as always is a careful assessment as treating an
identified cause is the most effective approach e.g. pain
• Manage environmental issues
• Psychosocial interventions
• Antidepressants not very effective but appropriate to trial esp
if history of depression
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Biological Treatments in Severe
Psychosis
• Focus on the patient
• If very distressed focus on their distress and targeting this.
• Often if the patient is very agitated and/or aggressive they are
in a great deal of distress
• Can trial benzodiazepines, antipsychotic medications or
anticonvulsants depending on the circumstances
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continued
• All medications have a high risk of serious side
effects on this group of patients
• Importance careful thought is given to commencing
• Start at low doses and review need regularly
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What to do if you are concerned about
yourself or a loved one?
• First step is an appointment with your GP for an assessment
• Your GP assessment may involve a physical examination, testing your
cognitive functioning, and some investigations
• Often you will need to see your GP more than once – there may be a
Nurse Practitioner at the practice who will become involved
• Your GP can then refer to appropriate services as required
• You may be referred for further assessment
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Referrals which may occur
• Specialist/ specialist team for further assessment and
treatment e.g. private specialist, Aged Care Team, Older
Persons Mental Health Team
• Aged Care Assessment Team
• Service Providers e.g. Meals on Wheels, home help
• Alzheimer’s Australia
• Community organisations offering support for people with
particular problems
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How to decide which services?
• This needs to be part of the individual plan and depends on
needs
• The needs will change over time.
• It is important to have a key person who can help coordinate
• This may be the GP, Nurse Practitioner, Community Options,
Case Manager, or sometimes the specialist involved.
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Further Information
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Beyond Blue website
Black Dog Institute website
Alzheimer’s Australia website
Understanding Dementia Massive Open Online Course – Wicking
Dementia Centre website
Tas Memory Clinic
Dementia Behaviour Management & Advisory Service (DBMAS) 1800 699
799
Lifeline 13 11 14
Better Access to Mental Heath Care Initiative