wicking dementia research and education centre is it depression, is it dementia or both? dr joanna...

Wicking Dementia Research and Education Centre

IS IT DEPRESSION, IS IT DEMENTIA OR BOTH?

Dr Joanna BakasConsultant Psychiatrist

Dr Kate-Ellen ElliottClinical Psychologist


What is dementia?• 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


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


What is depression?

• 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


What is depression (2)• 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


Symptoms in common

• Amotivation• Cognitive changes• Worry about memory!• Difficulty making decisions and problem solving• Anxiety and agitation


Both occur due to changes in the brain Dementia

Depression

• Changes in brain chemistry - – Serotonin– Norepinephrine – Dopamine


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.


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.


Depression in older adultsSub-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


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


MANAGEMENT PRINCIPALS

• Multimodal• Biopsychosocial approach• Importance of careful assessment so an

individualised treatment plan can be made• Reassessment as things can change


DEPRESSION TREATMENT

• All the above relevant


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.


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).


Psychological Treatments For Depression• Some evidence to support

• 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


Social Issues/ Factors

• Housing• Income / Employment• Family problems• Support network - relationships – quality over

quantity• Education


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


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


EARLY DEMENTIAPsychosocial Treatments• Person-Centered Care • Cognitive Behavioural Therapy

• 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


EARLY DEMENTIAPsychosocial Treatments Continued…• Caregiver focused therapy

• 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


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


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


MODERATE - SEVERE DEMENTIAPsychosocial 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


MODERATE - SERVERE DEMENTIAPsychosocial 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.


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)


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


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


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


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


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


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.


Further Information• 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

wicking dementia research and education centre is it depression, is it dementia or both? dr joanna...

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