PART 1 dad patients - Who are they?

Transcription

1 7/0/6 UE..4 Spécificités des méthodes et outils d évaluation Dépression / Apathie Diagnostic / Evaluation PART dad patients - Who are they? dad: Depression of Alzheimer s Disease dad patients Who are they? 4 Depression in old age: general concept Depression as one neuropsychiatric symptom of dementia Diagnosis of depression in AD Pharmacological treatment of depression in AD

2 7/0/6 Depression in old age: general concept 4 The Classical Depressive Symptoms according to DSM* Other somatic complaints DSM-V Core symptoms Typical symptoms Pessimistic Associated symptoms Low self esteem Significant weight loss or weight gain Decrease or increase of appetite Sleep disorders Hopelessness Recurrent thought of death Suicide ideation or attempts Depressed mood Loss of pleasure Agitation or Retardation Fatigue Loss of energy Concentrating difficulty Indecisivness Anxiety Feeling of Worthlessness or guilt Social isolation Withdrawal Irritability * clinically significant impairment in social, occupational or other functioning minimum 5 symptoms present during the same - week period (one is either depressed mood or loss of interest 5 Depression in the elderly Fully characterized major depression is less common than depressive symptoms, which are as frequent as in earlier life Depressed mood may not be the major complaint Somatic (e.g, pain) and cognitive complaints may dominate Anxiety, irritability and apathy are more frequent than in earlier life 6

3 7/0/6 Depression as one neuropsychiatric symptom of Dementia 7 Depression as one neuropsychiatric symptom of Dementia Cognitive Symptoms Memory Language Attention Apraxia Non-Cogni(ve Symptoms Apathy Depression Agita>on Psycho>c symptoms Loss of Autonomy in Activities of Daily Living Increase in Caregiver Burden Depression in AD Very common: Prevalence of 77% over a 5-year period* Often associated with apathy and increase in irritability No clear association between dementia severity and depression Increases the burden of both patients and caregivers Is associated with a greater decline in quality of life** Earlier institutionalization** Increased risk of mortality** Has a significant economic impact *Steinberg et al., 008; **Lyketsos CG et al., 00; Fernández-Martínez et al., 008 9

4 7/0/6 Prevalence of neuropsychiatric symptoms over a 5-year period 408 patients: 6% AD % VaD 6% mixed 0% other dementias > 65 years old Five-year prevalence of NPI symptoms (NPI >0) in the Cache County Study (Steinberg et al., 008). Severity of AD and prevalence of depression N = 499 AD patients REAL. Fr study, Benoit & al; Rev Med Int, 00 Depression in Alzheimer s Disease Sleep disorders Psychomotor changes Irritability Disruption in appetite Dementia Depressed mood Decreased pleasure in response to usual activities Fatigue Loss of energy Thoughts of death Feeling of worthlessness Social isolation Withdrawal minimum symptoms present during the same - week period (one is either depressed mood or decreased pleasure in response to usual activities) 4

5 7/0/6 Depression in AD depression in elderly dad Higher frequency of Motivational Disturbances such as: fatigue psychomotor slowing apathy Depression in elderly Higher frequency of Mood Symptoms such as: depressed mood anxiety suicidality sleep and appetite disturbances Diagnosis of depression in AD and overlaps 4 Diagnosis of depression in AD In clinical practice, diagnosis of depression in AD includes: a review of patient s medical history a physical examination a cognitive examination a behavioural examination including suicidal ideation interviews with family members (informants)* Provisional NIMH Diagnostic Criteria for Depression of AD used to define patients with AD and depression Rating scales appropriate for measuring effects of a study drug in a clinical trial with demented patients: NPI and CSDD * Teng et al.,

6 7/0/6 NIMH-dAD (/) A. Three (or more) of the following symptoms must be present during the same -week period and represent a change from previous functioning. At least one of the symptoms must either be either. or.. Clinically significant depressed mood. Decreased positive affect or pleasure in response to social contacts and usual activities. Social isolation or withdrawal 4. Disruption in appetite 5. Disruption in sleep 6. Psychomotor changes 7. Irritability 8. Fatigue or loss of energy 9. Feelings of worthlessness, hopelessness, or excessive or inappropriate guilt 0. Recurrent thoughts of death, suicidal ideation, plan or attempt Adapted from Olin et al NIMH-dAD (/) B. All criteria are met for Dementia of the Alzheimer Type (DSM-IV-TR) C. The symptoms cause clinically significant distress or disruption in functioning D. The symptoms do not occur exclusively in the course of delirium E. The symptoms are not due to the direct physiological effects of a substance F. The symptoms are not better accounted for by other conditions such as bereavement, psychosis of Alzheimer disease or substance-related disorders Adapted from Olin et al NIMH-dAD (Results) The baseline frequency of depression using NIMH-dAD criteria (44%) was higher than that obtained using: - DSM-IV criteria for major depression or minor depression - established cut-offs for the CSDD - GDS NIMH-dAD criteria correctly identified all patients meeting DSM-IV criteria for major depression NIMH-dAD correlated well with DSM-IV criteria for major or minor depression 94% sensitivity and 85% specificity Conclusions The NIMH-dAD criteria identify a greater proportion of AD patients as depressed than several other established tools. Teng et al., 008 6

7 7/0/6 Difficulties encountered in daily clinical practice Differentiating between depression in AD and delirium (e.g. if leading symptoms are: agitation/retardation; cognitive worsening) Differentiating between depression in AD and apathy in AD (e.g. if leading symptoms are: loss of drive, loss of emotion, less goal-directed cognition) Difficulties Patient's loss of insight/ difficulty articulating symptoms due to dementia Caregiver may themselves be depressed due to the daily burden * Concomitant treatment (e.g. sedation, restlessness, blurred symptomatology) * MacKenzie TB et al, Am J Psychiatry, Diagnostic criteria for apathy!loss of or diminished motivation in comparison to the patient s previous level of functioning and which is not consistent with his age or culture for at least 4 weeks!these changes in motivation may be reported by the patient himself or by the observations of others!loss of, or diminished (min / features) goal-directed behaviour goal-directed cognitive activity interest emotion 0 Depression in AD Apathy Depression: emotional disturbance Apathy: motivational disturbance Depressed Mood Inability to experience pleasure from activities usually found enjoyable (Anhedonia) Fatigue Withdrawal Loss of interest Cognitive worsening Irritability Diminished motivation (also to do things usually found enjoyable) Blunted Emotion 7

8 7/0/6 Depression in AD Apathy Benoit et al., 0: N = 74 ; Age=80±6.6 years; M/F=8/6%; MMSE =. ±. Depression Diagnosis Apathy Diagnosis 4 Treatment of depression in AD 4 Pharmacological Treatment of dad!no drug currently approved by regulatory agencies for the treatment of depressive symptoms in AD!DIADS- study (RCT, sertraline vs placebo; n=): n.s. symptom changes, response and remission rates!hta-sadd study (RCT, sertraline, mirtazapine, placebo; n=6 ): n.s.!if a patient presents with antidepressant medication it may have been prescribed for treatment of anxiety in general practice!treatment of depression associated with improved cognitive performance Rosenberg et al, 00; Banerjee et al., 0; Leong, 04 RCT: Randomised Clinical Trial 4 8

9 7/0/6 4 Non-Pharmacological Treatment of dad!occupational therapy has shown to reduce behavioral symptoms in AD including depression and to improve activities of daily living!animal-assisted therapy has been shown to be effective in treating apathy, agitation and depression in AD as well as deficits in communication and social interaction!reminiscence therapy in combination with productive activity significantly reduces depression in patients with AD e.g. Holthoff et al., 0 ; Bernabei et al, 04; Nakamae et al, 04 5 Conclusions 4 Depression is an emotional disturbance and highly disabling in old age. Depression in AD jeopardizes ADL and promotes institutionalization. Apathy is a motivational disturbance often encountered in dementia and may be mistaken as depressive symptom. Depression in AD is difficult to manage as there is lack of effective pharmacological therapy. It is necessary to search for a new treatment strategy. 6 PART Assessment of depressive symptoms in dad patients 7 9

10 7/0/6 Assessment of depressive symptoms in dad patients Different types of assessment (GDS, NPI, CSDD ) Neuropsychiatric Inventory (NPI) Cornell Scale for Depression in Dementia (CSDD) 8 Different types of assessment The point of view of The Patient + - GDS The Caregiver + - NPI The Clinician + - MADRS CSDD 9 Neuropsychiatric Inventory (NPI) domains scores Delusion Hallucination For each domain Agitation Frequency x Severity is scored by multiplying Depression severity (-) by frequency (-4) Anxiety Euphoria FxS from range 0 - Apathy Disinhibition Irritability Aberrant motor behaviour Sleep problems Eating problems 0 0

11 7/0/6 NPI Dysphoria domain (/) Does (S) seem sad or depressed? Does (S) say that he/she feels sad or depressed? (P) Yes: No: Responses should be based on the past 4 weeks. Caregiver Interview* Frequency 0-4 Severity 0- NPI Dysphoria domain (/) Does (S) seem sad or depressed? Does (S) say that he/she feels sad or depressed? (P) Yes: No:. Does (S) have periods of tearfulness or sobbing that seem to indicate sadness?. Does (S) say he/she is sad or in low spirits or acts as if he/she is sad or in low spirits?. Does (S) put him/herself down or say that he/she feels like a failure? 4. Does (S) seem very discouraged or say he/she has no future? 5. Does (S) say he/she is a burden to the family and that the family would be better off without him/her? 6. Does (S) express a wish for death or talk about killing him/herself? 7. Does (S) say that he/she is a bad person and deserves to be punished? Cornell Scale for Depression in Dementia (CSDD) (/) Mood Related Signs Anxiety Sadness Lack of reactivity to pleasant events: Irritability Behavioral disturbances Agitation Retardation Multiple physical complaints: Loss of interest Ideational Disturbance Suicide Self-depreciation Pessimism Mood-Congruent Delusions Physical Signs Appetite Loss Weight Loss Lack of energy Cyclic Functions Diurnal variation of mood Difficulty falling Asleep Multiple awakenings during sleep Early Morning awakenings

12 7/0/6 Cornell Scale for Depression in Dementia (CSDD) (/) The clinician rating is based on all available information coming from the patient, caregiver interview and any additional materials (e.g., chart notes) SCORING SYSTEM ü 0= absent ü = mild to intermittent ü = severe ü 9999= unable to evaluate 4