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DIABETES, DEPRESSION AND DEMENTIAA Clinician's Guide To Detection, Intervention and Prevention

Mark Aksamit MPAS, PA-C

ABOUT ME

Physician Assistant in Psychiatry at Nebraska Medicine Assistant Professor in the UNMC PA Program Unique Approach To Patient Care Type 1 Diabetes Since Age 7

DISCLOSURES

Formerly on the Allergan Speaker Bureau for Vraylar and Viibryd

Nothing else to disclose

BRIEF OVERVIEW

General Facts About Diabetes, Depression And Dementia The Connection Between The Three D’s Detection of Diabetes, Depression and Dementia in Different

Populations Your Role in Prevention and Intervention Integrative Medicine Being Advocates For Our Patients Resources Questions

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TYPE 1 DIABETES AND DEPRESSIONGENERAL FACTS

Higher rates of depression in children/adolescents with diabetes than general population [1]

Highest rates first year after diagnosis and adolescents [1,2]

Depression impacts adherence [3]

Associated with worse glycemic control and complications [4,5]

TYPE 2 DIABETES AND DEPRESSIONGENERAL FACTS

Much of the same Depression leads to a substantial increase in risk of Type 2

Diabetes [6]

Type 2 Diabetes increases risk for Depression [7]

Depression impacts adherence [3]

Associated with worse glycemic control and complications [4,5]

DSM-5 DIAGNOSTIC CRITERIA FOR MDD [8]

Significant weight loss (when not dieting) or weight gain, or a marked increase or decrease in appetite nearly every day

Excessive sleepiness or insomnia Agitation and restlessness Fatigue Feelings of worthlessness or excessive inappropriate guilt nearly

every day Diminished ability to think, concentrate or make decisions Recurrent thoughts of death or suicide

Depressed mood or anhedonia with 4 or more symptoms most of the day, nearly every day, during a 2 week period:

DIABETES RELATED DISTRESS VS DEPRESSION

These two terms are not equal and important to know the differences.

Diabetes Related Distress is far more prevalent than Depression [7] DRD responds very well to Diabetes self-management education

and support (DSME/S) and improves glycemic control [7] DSME/S can also help reduce rates of depression in Diabetes [7] However, clinical depression and severe DRD need referral for

specialist care (Psych).

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DEMENTIA

Classified as a “syndrome” in which there is deterioration in memory, thinking, behavior and the ability to perform everyday activities [9]

NOT A NORMAL PART OF AGING [9]

Encompasses many different types of conditions, but Alzheimer’s is most prevalent [9]

“Dementia is one of the major causes of disability and dependency among older people worldwide” [9]

“Dementia has a physical, psychological, social, and economical impact, not only on people with dementia, but also on their careers, families and society at large” [9]

DEMENTIA AND DIABETES

Diabetes infers higher risk of vascular complications and the brain is no different

Many potential mechanisms for why Diabetes increases risk for Dementia, but still unclear [10]

Homogeneity among cardiovascular problems seems most likely [10]

Glucose not used properly in brains of people who suffer from AD [10]

In Vascular Dementia brain cells die due to lack of oxygen [10]

DEMENTIA AND DIABETES

[27]

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DEMENTIA AND DEPRESSION

Prodromal Symptom or Independent Risk Factor? [14]

Biologically plausible that depression increases risk of dementia [14]

Are Antidepressants protective? [26]

DIABETES, DEPRESSION AND DEMENTIA

Summarize the correlative and possible causal links between these three conditions

Intimate connections and possible means for intervention?

DIABETES

DEPRESSION

DEMENTIA

DETECTION OF DIABETES RISK FACTORS — Identifying risk factors for diabetes may help to target specific patient groups for

screening. Risk factors for diabetes include the following

●Age ≥45 years

●Overweight (body mass index [BMI] ≥25 kg/m2); the risk with increased weight is also a continuum, with significantly increased risk for obese individuals (eg, BMI ≥30 kg/m2)

●Diabetes mellitus in a first-degree relative

●Sedentary lifestyle

●High-risk ethnic or racial group (eg, African American, Hispanic, Native American, Asian American, and Pacific Islanders)

●History of gestational diabetes mellitus

●Hypertension (blood pressure ≥140/90 mmHg)

●Dyslipidemia (serum high-density lipoprotein cholesterol concentration ≤35 mg/dL [0.9 mmol/L] and/or serum triglyceride concentration ≥250 mg/dL [2.8 mmol/L])

●A1C ≥5.7 percent, impaired glucose tolerance (IGT) or impaired fasting glucose (IFG)

●Polycystic ovary syndrome

●History of vascular disease

DETECTION OF DIABETES

Polyuria Polydipsia

Polyphagia

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DETECTION OF DEPRESSION

Utilize Screening ToolsDSM-5 Diagnostic CriteriaRemember SIGECAPS

DETECTION OF DEPRESSION

DSM-5 DIAGNOSTIC CRITERIA FOR MDD [8]

Significant weight loss (when not dieting) or weight gain, or a marked increase or decrease in appetite nearly every day

Excessive sleepiness or insomnia Agitation and restlessness Fatigue Feelings of worthlessness or excessive inappropriate guilt nearly

every day Diminished ability to think, concentrate or make decisions Recurrent thoughts of death or suicide

Depressed mood or anhedonia with 4 or more symptoms most of the day, nearly every day, during a 2 week period:

DETECTION OF DEMENTIA

Classified as a “syndrome” in which there is deterioration in memory, thinking, behavior and the ability to perform everyday activities [9]

USE SCREENING TOOLS Folstein MMSE MOCA

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DETECTION OF DEMENTIA

DETECTION OF DEMENTIA

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DIABETES, DEPRESSION AND DEMENTIA

Feel comfortable “detecting” diabetes, depression and dementia

Utilize screening tools for detection

Interpretation of scores from screening tools

Know your resources and when to refer

INTERVENTION IN DIABETES

DSME/S to improve glycemic control

Education is not enough

Encourage Exercise and Dietary Changes

Empathy and Support

Bariatric surgery?

INTERVENTION IN DEPRESSION

Refer, Refer, ReferAnti-depressantsPsychotherapyOther Modalities?

INTERVENTION IN DEMENTIA

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DIABETES, DEPRESSION AND DEMENTIA

Putting It All TogetherWhat Can you do?Feasibility of Interventions in clinical practiceBarriers to Intervention

PREVENTION OF DIABETES

Promote Wellness Physical ActivityBest Prevention is Early Intervention?Education again, is it enough?

PREVENTION OF DEPRESSION

Recognizing risk factorsDiabetes Burnout vs. DepressionDon’t forget about the value of

psychotherapyTreat if neededScreening

PREVENTION OF DEMENTIA

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DIABETES, DEPRESSION AND DEMENTIA

Significant heterogeneity amongst detection, intervention and prevention

Putting it all together

INTEGRATIVE MEDICINEStay within the scope of your practice,

but…..IF YOU HAVE THE KNOWLEDGE USE IT!Know your resourcesEvery interaction with a patient is an

opportunity

ADVOCATING FOR YOUR PATIENTS

Communication, Communication, Communication Identify where you may be lacking and work to

improve Adhere to appropriate boundaries, but be

empathetic Not one size fits all Help to coordinate care if possible

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QUESTIONS REFERENCES1. Grey M, Whittemore R, Tamborlane W. Depression in type 1 diabetes in children:

natural history and correlates. J Psychosom Res 2002; 53:907.2. Kovacs M, Goldston D, Obrosky DS, Bonar LK. Psychiatric disorders in youths with

IDDM: rates and risk factors. Diabetes Care 1997; 20:36.3. https://www.uptodate.com/contents/complications-and-screening-in-children-

and-adolescents-with-type-1-diabetes-mellitus/abstract/204. Stewart SM, Rao U, Emslie GJ, et al. Depressive symptoms predict hospitalization

for adolescents with type 1 diabetes mellitus. Pediatrics 2005; 115:1315.5. Lawrence JM, Standiford DA, Loots B, et al. Prevalence and correlates of

depressed mood among youth with diabetes: the SEARCH for Diabetes in Youth study. Pediatrics 2006; 117:1348.

6. Diabetes Care. 2008 Dec; 31(12): 2383–2390. doi: [10.2337/dc08-0985]7. Powers, M. A., Bardsley, J., Cypress, M., Duker, P., Funnell, M. M., Fischl, A. H., …

Vivian, E. (2017). Diabetes Self-management Education and Support in Type 2 Diabetes: A Joint Position Statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. The Diabetes Educator, 43(1), 40–53. https://doi.org/10.1177/0145721716689694

8. https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425596.dsm04#BCFJBIIA

REFERENCES9. http://www.who.int/news-room/fact-sheets/detail/dementia10. http://alzheimer.ca/en/Home/About-dementia/Alzheimer-s-disease/Risk-factors/Diabetes-dementia-connection11. Yaffe K, et al. JAMA Intern Med. 2013;173:1300 https://doi.org/10.1001/jamainternmed.2013.6176[PMC free article] [PubMed]12. Circular association of hypoglycemia with dementia.(PMID:29080555)Meyyappan D, Goodwin JS, Mehta HB.Aging (Albany NY) [2017]13. Shih et al., 2018 I.-F. Shih, K. Paul, M. Haan, Y. Yu, B. RitzPhysical activity modifies the influence of apolipoprotein e ε4 allele and type 2 diabetes on dementia and cognitive impairment among older Mexican Americans Alzheimers Dement., 14 (1) (2018), pp. 1-914. Livingston G., Sommerlad A., Orgeta V., Costafreda S.G., Huntley J., Ames D. Dementia prevention, intervention, and care. Lancet. 2017;390:2673–2734.15. Pieper MJ, Francke AL, van der Steen JT, et al. Effects of a Stepwise Multidisciplinary Intervention for Challenging Behavior in Advanced Dementia: A Cluster Randomized Controlled Trial. J Am Geriatr Soc 2016; 64:261.16. Reus VI, Fochtmann LJ, Eyler AE, et al. The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia. Am J Psychiatry 2016; 173:543.17. Wang J, Yu JT, Wang HF, et al. Pharmacological treatment of neuropsychiatric symptoms in Alzheimer's disease: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2015; 86:101.18. Kiosses DN, Ravdin LD, Gross JJ, et al. Problem adaptation therapy for older adults with major depression and cognitive impairment: a randomized clinical trial. JAMA Psychiatry 2015; 72:22.

REFERENCES19. Lavretsky H, Reinlieb M, St Cyr N, et al. Citalopram, methylphenidate, or their combination in geriatric depression: a randomized, double-blind, placebo-controlled trial. Am J Psychiatry 2015; 172:561.

20. Porsteinsson AP, Drye LT, Pollock BG, et al. Effect of citalopram on agitation in Alzheimer disease: the CitAD randomized clinical trial. JAMA 2014; 311:682.

21. Orgeta V, Qazi A, Spector AE, Orrell M. Psychological treatments for depression and anxiety in dementia and mild cognitive impairment. Cochrane Database Syst Rev 2014; :CD009125.

22. Declercq T, Petrovic M, Azermai M, et al. Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev 2013; :CD007726.

23. Livingston G, Barber J, Rapaport P, et al. Clinical effectiveness of a manual based coping strategy programme (START, STrAtegiesfor RelaTives) in promoting the mental health of carers of family members with dementia: pragmatic randomised controlled trial. BMJ 2013; 347:f6276.

24. A Singh-Manoux, A Dugravot, A Fournier, et al.Trajectories of depressive symptoms before diagnosis of dementia a 28-year follow-up studyJAMA Psychiatry (2017) published online May 17. DOI:10.1001/jamapsychiatry.2017.0660

25. Vascular disease, depression, and dementiaJ Am Geriatr Soc, 51 (2003), pp. 1178-1180

26. YI Sheline, T West, K Yarasheski, et al.An antidepressant decreases CSF Aβ production in healthy individuals and in transgenic AD miceSci Transl Med, 6 (2014), p. 236re4

27. Parikh NM, Morgan R, Kunik ME, et al. Risk factors for dementia in patients over 65 with diabetes. Int J Geriatr Psychiatry. 2010;26:749-757.

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REFERENCES

28. https://www.uptodate.com/contents/screening-for-type-2-diabetes-mellitus search=screening%20for%20diabetes&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

29. https://i2.wp.com/www.verywellhealth.com/thmb/JMief1rFR5wFRogKp5KlMfHaFXk=/1500x1000/filters:no_upscale():max_bytes(150000):strip_icc()/alzheimers-and-montreal-cognitive-assessment-moca-98617-5bb7c858c9e77c0051582af1.png