Treatments for Depression in Ederly Individuals with Dementia
Depression in Dementia
Dementia itself isn't a disease, but a configuration of symptoms induced by diseases and disorders that impact the mind, including Alzheimer’s disease (AD), Parkinson’s disease (PD), diffuse Lewy body disease, strokes, and others. Dementia involves increasing deprivation of retention and other cognitive routines, such as problem-solving and emotional restraint. The most primal identifiable stage of dementia, modest cognitive impairment (MCI), doesn't always lead to dementia; for those who do acquire dementia, abilities to independently execute elementary activities of day-to-day living (ADLs) and instrumental activities of daily living (IADLs) are broadly afflicted as the condition advances.
Behavioral and mental symptoms of dementia (BPSD), likewise often referred to as neuropsychiatric symptoms of dementia, affect up to 95% of those with dementia during the course of the malady. Symptoms of depression are particularly frequent in MCI and throughout the course of dementia. Reported preponderance of depression or depressive symptoms in individuals with dementia runs from 0% to 96%,2-5 while modest to high ranges of depression or its symptoms are consistently reported for individuals with MCI (ie, 36% by Palmer and colleagues; 63.3% by Solfrizzi and colleagues; 39% by Hwang and colleagues). The broad range of prevalence for depression in dementia is owed to many elements, including divergences in investigators’ focus on symptoms versus specifically delineated depressive disorders, various study samples deviating in causes of dementia, stage of illness, nation of residence, and placement of patient, as well as fluctuation in the instruments employed to appraise depressive symptoms and disorders. A lately published evidence-based practice guideline offers a practicable approach to depression appraisal in individuals with dementia; an overview of the guideline algorithm is rendered in the Table. The guideline can be accessed at the National Guideline Clearinghouse, a public resource for evidence-based clinical practice guidelines.
Results of Depression in Dementia
The occurrence of depression in folks with MCI or dementia can lead to a number of damaging consequences. E.g., Preexistent depression has been described as a forecaster of, or risk factor for, future dementia. One meta-analysis forecast that individuals undergoing depression have about twice the risk of acquiring dementia as those without an antecedent history of depression, and newer study determinations agree. Depression might as well be a risk factor for advancement from MCI to dementia. Many studies report an connection between baseline depressive symptoms in participants with MCI and a subsequent advancement to dementia.
Comorbidity of cognitive damage and depression has been affiliated with expanded mortality, decreased calibre of life. and increases in health care provider encumbrance and distress. Perhaps due to the destructive impact on caregivers, comorbid depression and cognitive impairment are connected with greater rates of institutionalization of the aid recipient with dementia.
Pharmacological handling of clinical depression in Dementia
Both pharmacologic and nonpharmacologic treatment approaches have been ascertained to be facilitatory in subduing depression in cognitive impairment and dementia. Pharmacologic treatment of depression in patients with dementia, though frequent, introduces a few unique troubles. Patients with dementia have many more comorbid maladies than those without dementia, with approximately 60% of those with AD possessing 3 or more medical conditions. This intensified degree of comorbidity results in the utilisation of manifold medicines. Consequently, drug interactions and polypharmacy could help stimulate BPSD in many patients with dementia, or may play a part in driving these patients’ sometimes irregular reactions to the drugs employed to care for BPSD. Given their physiologic and cognitive infirmity, individuals with dementia may likewise be especially supersensitive to unfavorable forces. Because persons with dementia may be less competent to communicate, clinicians and caretakers must cautiously watch their conduct for evidence of harmful events when untested medicines are introduced. Prescribing new medicines designated to care for depression or additional BPSD in these patients should always be made employing the well-known proverb originated for dosing the aged, “Start low, and go slow.”
Antidepressants are often ordered for treatment of depression in dementia. A recent meta-analysis studied treatment of depression with tricylic antidepressants (TCAs; imipramine and clomipramine), and selective serotonin reuptake inhibitors (SSRIs; sertraline and fluoxetine) in five reports on patients with dementia. Treatment reaction and remission was superlative to placebo in the aggregated sample, but considerable declinations in cognitive scores came about during the utilisation of TCAs in both studies using them. Follow-ups of research on the pharmacological treatment of BPSD in common suggest favorable outcomes of several antidepressants (for instance, sertraline, fluoxetine, citalopram, trazodone) on depression in dementia, with citalopram and sertraline being the most ordinarily prescribed. Case accounts and modest pilot reports signal that additional antidepressants, including buspirone and mirtazapine, might improve depression in patients with dementia, but no sizable tests have been executed in this universe up to now. The practice guidepost released in 2007 by the Work Group on Alzheimer’s Disease and Other Dementias of the American Psychiatric Association presently endorses SSRIs as the foremost pharmacological treatment of choice for depression in dementia, as SSRIs incline to be better endured than different antidepressants. Nonetheless, the Work Group advises that if patients with dementia can't abide greater doses when required for subsidence of depression, trials of alternate antidepressants such as bupropion, venlafaxine, and mirtazapine could be regarded.
Newer medicines that express possible promise in the treatment of depression in dementia include anticholinergics, anticonvulsants, and memantine.
Diminished cholinergic action, chiefly ensuing from diminished acetylcholine concentrations induced by dementia-related neurologic alterations, has been affiliated with lessened cognitive ability in dementia, as well as gains in BPSD, including anxiousness and clinical depression. Cholinesterase inhibitors have been employed to successfully target these problems by maximizing levels of acetylcholine in patients with mild-to-moderate dementia. In particular, a new randomized controlled trial run showed betterment in depression scores of patients with dementia, as assessed by the Hamilton Depression Scale, for patients given rivastigmine or a commingled regimen of rivastigmine and fluoxetine, as compared to placebo.
Anticonvulsants, by their transition of gamma-aminobutyric acid (GABA), might be a different category of agents for addressing BPSD. GABA concentrations are oftentimes diminished in cortical areas of the brain of patients with dementia, and medicines that increment GABA levels have been evidenced to improve mood troubles. Even so, trials of the anticonvulsant carbamazepine to care for BPSD have afforded inconsistent outcomes, or have not covered data on depression. At least one clinical test of valproate, another anticonvulsant drug, resulted in substantial improvement in melancholic, grievous, and nervous demeanors, but the outcomes of additional small trials of valproate are at odds. Exploratory trials of the anticonvulsant drug lamotrigine in older patients with dementia also noticed improvement in symptoms of agitation and clinical depression.
Memantine, a drug that scales down excessive glutamate receptor signaling, has also been analysed in patients with dementia. Glutamate signaling is meaningful for learning and retention, but in many patients with dementia it might increase to “oversignaling” levels that demolish neurons. A recent survey and meta-analysis of the research on memantine for the treatment of psychological symptoms of dementia indicated moderate but meaningful improvements as measured by the Neuropsychiatric Inventory, with minor contrary effects.
In summary, an assortment of pharmacologic treatments have some efficaciousness in the handling of clinical depression in dementia, but caution must be exerted in their employment with this universe of typically weak aged individuals to head off harmful consequences. Alexopoulos and fellows built an expert consensus response after appraising fifty experts in dementia from North America on favoured, secondary, and objectionable treatment alternatives for BPSD. The broad consensus was that SSRIs were the desirable pharmacological treatment for depression in patients with dementia. Additional inquiry seems to be necessitated to demonstrate the effects of both older and more novel pharmacological alternatives on depression in individuals with dementia.
Nonpharmacologic Treatments for Depression in Dementia
Clinical guidelines particularise the employment of nonpharmacologic treatments for BPSD before pharmacologic treatments are attempted. Nonpharmacologic therapies that specifically target depression or its symptoms fall more or less into 3 classes: emotion-oriented therapies, abbreviated psychotherapies, and sensational stimulus therapies.
The chief intent of emotion-oriented therapies is to match the therapy to emotional wants of folks with dementia, and by doing so, better their calibre of living, social performance, and power to deal with the cognitive, emotional, and social issues of the disease as they subjectively undergo them. Illustrations of emotion-oriented approaches include recollection, realism, validation, and artificial presence therapy.
Reminiscence therapy encourages individuals with dementia to discuss their pasts, typically employing retentiveness aids such as past family photographs and personal objects. Reality orientation therapy is grounded upon the hypothesis that inability to orient themselves abbreviates the ability of those with dementia to operate, and that mental confusion can be kept down by imparting recurrent orientation clues, such as the time of day, date, time of year, or names. Validation therapy presumes that the individual with dementia might decide to retire to an inner reality founded on emotions, instead of seeking to grapple with failing rational abilities. The therapist accepts the consequent disorientation of an individual with dementia and corroborates his or her assumed feelings, rendering a backdrop for substantive conversations addressing their emotions. Simulated presence therapy requires exposing an person with dementia to audio or videotaped transcriptions of loved ones.
Regrettably, the restricted literature accessible on emotion-oriented therapies in patients with dementia includes few reports with depression as an assessed outcome. Even when these results are described, determinations on the effects of emotion-oriented therapies on these and additional BPSD are contradictory and are grounded on constricted or methodologically refutable studies. In spite of many affirmative clinical studies of efficacy for these intercessions, there's presently inadequate grounds for their effectuality in abbreviating any BPSD, and virtually no research offering information on their effects on depression. Still, many anecdotical and research articles of nonsubjective effectivity, and the client-centered nature of these personalized therapies, indicate that they may still turn out to be useful. More methodologically stable, larger, and well-controlled randomized trials are recommended by their protagonists (for example, Finnema and colleagues).
Brief psychotherapies that have been applied with some success in individuals with depression in dementia include behavior therapy and cognitive-behavioral therapies (CBTs). Behavioral therapies are more generally employed in the advanced phases of dementia, while modified CBTs seem to be more productive with those in the more premature stages of cognitive declination.
Behavior therapy necessitates a time period of detailed appraisal in which the triggers, behaviors, and reinforcers (a.k.a. the ABC: Antecedents, Behaviors and Consequences) are distinguished, and their relationships made crystal clear to the patient. Interventions are then founded on an analysis of these determinations. There are many interventions for patients with dementia based on behavior theory, including token economy, advanced muscle relaxation, imaging, and social skills training, to name a few. All the same, most trials of such therapies don't center on depression as an resultant. An exception is behavioral programming based on Lewinsohn’s Pleasant Events model. The model has 3 core group factors: (1) explaining the approach to the patient, stressing that an individuals conduct is relevant to how he or she feels; (2) describing pleasing and unfavorable events in the patient’s day-to-day life, and helping patients to work at maximising the 1st and lessening the 2nd; and (3) explaining that relaxation and mood monitoring are instruments to aid the patient in improving. Logsdon and Teri built and corroborated a Pleasant Events Schedule—Alzheimer’s Disease (PES-AD) to help caregivers in carrying out an intercession for patients with dementia. Teri and colleagues employed this model to folks with dementia, and saw that depression scores improved in those who took part in a home-based program fusing exercise with behavioral direction training for caregivers; still, the outcomes of the behavioral management portion alone weren't analyzed. Lichtenberg and colleagues likewise analyzed the effect of a program established on this model on depression in nursing home occupants with dementia. They ascertained no differences on depression scores on either of 2 standardised scales employed, although statistically meaningful affirmative mood increases were noticeable.
While CBT is more ordinarily employed with caregivers of patients with dementia than with the patients themselves, some studies have examined the consequences of case-by-case or group CBT on BPSD, and on depression in particular. Teri and colleagues described clinical advances in depression scores on standardised values following CBT, employing 2 strategies for treating individuals with AD. Cognitive therapy was practiced with adults with modest dementia to challenge the individuals negative cognitions in order to scale down distortions, and enable the individual to render more accommodative means of regarding particular situations and events. Behavioral intervention (founded on the Lewinsohn’s Pleasant Events model identified above) was applied with adults with more modest or serious dementia. Koder also addressed the utilisation of CBT methods to address anxiety in 2 cases of elderly patients with cognitive deterioration, and described affirmatory outcomes.
Additional adjustments to CBT, in addition to targeting cognitive strategies to early-stage dementia and behavioral strategies to subsequent stages, require reducing the cognitive burden on the individual with dementia by expanding repetition, employing tangible models, and rendering retention aids, such as cue cards. Going through CBT with persons with dementia likewise necessitates an extremely organised format and uninterrupted supervising of the individual’s discernment of the curative material. Also, most CBT platforms for individuals with dementia involve their caregivers, both as CBT “managers” for the care receiver, and as treatment collaborators who frequently profit from the intercession likewise.
Early attempts likewise have been made to test the efficaciousness of a correlative strategy, problem-solving therapy (PST), in addressing depression in individuals with cognitive shortages. Specifically, Alexopoulos and colleagues noticed improvements in depression following PST in individuals with executive disfunction, while those with Mini-Mental State exam scores signaling MCI or dementia were screened out of the sample distribution. A lone case study determined that PST significantly bettered the depression scores and clinical profile of an elderly patient with PD and MCI, both short- and long-term (6 mo post-treatment). Nevertheless, additional research on the carrying out of PST in individuals with clinical depression with diagnosed MCI or dementia is required.
While there have been no methodologically stringent tests of CBT or PST to address clinical depression in individuals with dementia, involvement in this matter has been resurrected. Stanley and McNeese have lately accepted financial support from the National Institutes of Mental Health (NIMH) to lead a randomized controlled test of the impact of CBT on anxiousness in individuals with mild-to-moderate dementia, and they plan to appraise depression employing the Geriatric Depression Scale as a subordinate outcome, with resolutions anticipated in 2010. Additionally, Kiosses is presently leading an NIMH-funded trial of PST to care for elderly adults with depression and cognitive disablement, with results expected in 2011.
Sensory Stimulation Therapies
Sensory stimulation therapies that have been employed to care for BPSD include artwork/music therapy, aromatherapy, animal-assisted/pet therapy, activity therapies, massage/touch therapies, and multisensory approaches (for example, Snoezelen, reported below). The goals of these therapies run from betterment of mood to enhanced wellness to improvement in retentiveness. Analogous to the emotion-oriented therapies, few stringent reports have been executed, and results of efficaciousness are assorted, though reports from clinical observers are broadly very affirmative. The impact of receptive arousal therapies on clinical depression in dementia has encountered constricted attention, but their potentiality for efficacy looks advantageous.
Art therapy is conjectured to render folks with dementia with significant stimulation, improved cultural interaction, and an opportunity to practise personal choice. Clinical observation of individuals with dementia engaging in art therapy has showed that it can furnish pleasure and improve temper. Yet, participants in an art therapy programme analysed by Rusted and colleagues in reality demonstrated enlarged depression scores on 2 standardized measures over the run of a 40-week program, perhaps owing to feelings of failure in attaining a gratifying work of art. Reexaminations on art therapy in dementia indicate that additional and more demanding research is required to evaluate its possible benefits on depression in this population.
Many clinical accounts have depicted benefits acquired by folks with dementia from music therapy involving either listening or playing, although most call for listening. Lord and Garner ascertained that a grouping of nursing home occupants who regularly had music played to them, as compared to a comparison group who did not, received greater degrees of wellbeing, more effective social interaction, and betterments in autobiographic retention. More recently, Holmes and colleagues randomized patients with moderate-to-severe dementia and diagnosed indifference to conditions of soundless periods, recorded music, or live interactive music, and determined much fuller degrees of affirmative involvement in the live music circumstance than in the silence or recorded condition. Additional reports affirm the advantageous effects of music therapy on assorted BPSD other than depression, signaling that this fashion of intervention merits additional attention.
Aromatherapy is among the rapidest flourishing of all the reciprocal therapies. It seems to have many advantages over the pharmacological treatments widely applied for dementia, especially restriction of harmful effects from conventional pharmacotherapy. There have been a few advantageous outcomes from 3 controlled trials that have demonstrated statistically meaningful decreases in agitation, with superior conformity and tolerability. Still, the type of aromatherapy oils tested, technique of administration, and outcome measures employed deviated widely over the few obtainable studies, and depression hasn't been analysed as an outcome. Additional trials are called for before determinations can be made on the effectualness of aromatherapy for depression or other BPSD.
Animal-assisted therapy (AAT) has been described to diminish agitation and improve socialising in individuals with dementia in small, uncontrolled trials. Two small reports described reductions of apathy and detachment in individuals with dementia who were exposed to therapy dogs in a rest home setting. However, in the sole study that applied a measurement of depression, no meaningful modifications in depression came about. Additional studies with bigger samples and enlarged measurement are called for. In their reappraisal of the moderate literature accessible on AAT and dementia, Filan and Llewellyn-Jones90 reasoned that AAT may have advantageous effects on BPSD, but the length of these outcomes is unknowable, and studies are required to unsnarl the proportionate benefits acquired from “visiting” creatures versus “resident” animals. Conceivable interaction effects from double exposure of patient and faculty/caregivers to the animals during therapy likewise call for additional exploration.
Activity therapies include structured physical and recreational activities. A reexamination of 27 studies by Eggermont and Scherder reasoned that physical activity curricula can amend mood in patients with dementia, with a recent study showing that whole-body movement programs have a bigger positive impact than walking alone. One report noticed that depression scores improved in folks with dementia who took part in a home-based program merging exercise with behavioral management training for caregivers; regrettably, it's not conceivable to disencumber the effects of one intercession from the other. Another report with depression as an outcome ascertained that a semiweekly exercise programme improved ADL function in individuals with AD as compared to controls across a 1-year period of time, but had no impact on depression scale scores. These conflated outcomes signaled that activity therapy might be advantageous for depression in dementia, but reports need to concentrate closely on the effects of particular types of activities.
A critical review of massage and touch intercessions for dementia ascertained that the very confined sum of dependable evidence acquirable supported massage and touch interventions for anxiety affiliated with dementia, particularly hand massage for the proximate or short-run diminution of distraught demeanor. Cohen-Mansfield described reductions in anxiousness in 2 small trials, one involving day-to-day hand massage and therapeutic touch, and the other a hand massage with essential oils. Regrettably, no massage trials seem to have viewed depression as an outcome variable. Massage therapy, like other reciprocal and alternate medicine choices for dementia, compels more research to demonstrate its efficaciousness in BPSD, including depression.
Multisensory approaches generally require employing a room fashioned to allow for many types of sensorial arousal such as light (often in the shape of moving flexible-fiber optics), texture (cushions and vibratory pads), aroma, or sound. The employment of these resources is customized to the individual, and consequently not each of the accessible forms of stimulation may be applied in one sitting. One such approach, known as Snoezelen, allows for sensorial stimuli to arouse the basal senses of vision, sense of hearing, sense of touch, smack, and olfactory perception, by the usage of illuminating effects, tactile surfaces, contemplative music, and the scent of relaxing essential oils. A survey by Verkaik and colleagues renders some evidence that Snoezelen/Multisensory arousal in a multisensory room is useful in abbreviating apathy in individuals with late-stage dementia. A recent randomized controlled trial by Staal and colleagues likewise ascertained that patients on a gerontological psychiatrical unit obtaining Snoezelen and standardised psychiatric aid had diminished indifference and agitation scores, as well as augmented ADLs, as likened to patients receiving standard care exclusively. Though multisensory approaches to treatment of BPSD appear rather bright, there's a demand for more research-based evidence to inform and vindicate the employment of Snoezelen and suchlike multisensory approaches in dementia care.
An all-encompassing range of pharmacological and nonpharmacologic treatments have been employed to ease depression in individuals with cognitive impairment and dementia. Clinical consensus and research seem to confirm SSRIs as a primary alternative for the handling of depression in dementia. In patients who are nonresponsive or those with particular needs, additional medicines have been employed, including antipsychotics, anticholinergics, anticonvulsants, memantine, and complementary/secondary medicines. Added attention is called for in prescribing to this universe, due to the typically high degree of medical and psychiatric comorbidity and prospective trouble in appraising the responses of cognitively weakened persons.
Nonpharmacologic intercessions including emotion-oriented therapies, behavioral and cognitive-behavioral modification platforms, and integrated activity programs establish initial support for addressing depression, anxiety, and other BPSD. Sensory stimulation therapies such as artwork/music therapy, aromatherapy, animal-assisted/pet therapy, activity therapies, massage/touch therapies, and multisensory approaches display some promise for successful handling of depression in dementia, but additional and more stringent research is needed to show their validity.
Dr. Gellis has accepted funding support from National Institutes of Mental Health subsidization K01 MH071253 and the John A. Hartford Foundation. Dr. Brown has obtained funding support from National Institutes of Mental Health K01 MH0669421.
The writers describe no related fiscal relationships.