Holistic approach to assessing and treating depression in dementia

1. Holistic approach to assessing and treating depression in dementia Abhilash K. Desai MD Alzheimer’s Center of Excellence ThedaCare Behavioral Health

2. Nursing home residents • Major depression: 6-10% prevalence. 20-25% in non-demented residents. • 4.3% new Major depression over one year. • Minor depression: 25-33% prevalence. 7.4% new minor depression over one year. 23.5% will develop major depression over one year.

3. Depression in long term care • Comorbid anxiety and agitation is common with depression. • Dementia with depression is the most common category of depressive disorders. • Comorbid delusions is often seen along with depression in people with dementia. • Clinical practice guidelines by American Medical Directors Association recommended.

4. Nursing home residents • Up to 38% of newly admitted residents had depressive symptoms by day 14. • Treatment may need to start before admission. • Comprehensive strategy to prevent depression or reduce symptoms in newly admitted residents is needed.

5. Nursing home residents • 34% of residents had a reduction in their depressive symptoms by day 60!! • Only 41% of the residents who did not improve had treatment changes. • 54.3% still had major depression and 31.4% still had minor depression one year later!! • Re-evaluation of response to treatment must be done by 6 weeks and treatment modified as necessary.

6. Is it depression? • Symptoms: generally moderate to severe and persistent, moderate to severe impairment in functioning, suicidal ideas, psychotic symptoms. • Risk factors (new admission, change in environment, personal or family history of depression, new stressful losses, history of attempted suicide, alcohol abuse, certain medical illnesses and medications). • If not sure: consider watchful waiting.

7. Differential diagnosis • Normal sadness. • Clinical depression: • Depression without dementia (Major depression, Bipolar depression, other disorders with depression). • Dementia with depression. • Depression due to medical conditions or medications. • Each of the clinical depression categories could be with or without psychotic symptoms (delusions and hallucinations).

8. Depression without dementia • Onset: over days to weeks. Duration: at least 2 weeks. Generally weeks to few months. • Lack of fluctuation: symptoms occur on most days, most of the time. • Core symptoms: depressed mood, lack of interest or pleasure in normal activities, decreased energy, change in appetite and sleep pattern, impaired concentration, psychomotor agitation or slowness, suicidal ideas, guilt feelings (being a burden), feeling hopeless, helpless, worthless.

9. Depression without dementia • Often there are complains of memory problems and lack of effort in answering memory questions. ‘I don’t know’ answers to memory questions are frequent. • When they do give their best, memory tests (MMSE, clock drawing test) are normal. • Generally they have high medical comorbidity (post-stroke depression in 30-60%, Parkinson’s disease: 40%, certain cancers: 40%). • Depressive symptoms precede memory problems.

10. Dementia without depression • Impaired recent recall: forget recent events, ask questions repeatedly, repeats what they said frequently, disorientation to place, time, difficulty with instrumental activities of daily living (shopping, taking meds, driving) and as dementia progresses with basic activities of daily living (grooming, toileting, dressing). Gradual onset and slow but relentless progression over years.

11. Dementia without depression. • Generally do not complain of memory loss and often report that their memory is fine despite obvious memory and functional impairment. • Mood is not sad and they do not have anhedonia (lack of pleasure in activities that were previously pleasurable), do not have feelings of guilt or being a burden. • Cognitive tests (MMSE, clock drawing) are abnormal. • Apathy (lack of initiative and motivation) may be present.

12. Dementia with depression • The key sign of depression in people with dementia is ‘depressed affect’: the person looks depressed, is often tearful, has sleep and appetite problems, makes hopeless statements or says ‘help me, help me’ indicating a depressed affect. Most people with dementia generally say ‘no’ when asked if they are depressed. They generally say ‘yes’ to feeling lonely, bored, useless.

13. Dementia with depression • 20% have minor depression and 20% have major depression at some point in the course of dementia. • In advanced dementia, diagnosis relies on non-verbal cues. E.g. Irritability, anger, verbal and physical aggression, agitation, persistent moaning, yelling, wish to go home.

14. Disease burden • Reduced quality of life. • Independent predictor of mortality (as much as 50%) besides suicide. • Hospitalization. • Reduced ability to perform activities of daily living. • Increased physical pain.

15. Medical conditions as cause • B12 and folate vitamin deficiency. Check levels. • Thyroid disorder, Sleep Apnea, Pain. Check thyroid levels, consider sleep study, use pain scale. • Testosterone deficiency syndrome. Check free testosterone levels. Consider testosterone replacement therapy. • Medications: some antihypertensives, steroids, opioids, antiparkinson drugs, antipsychotics, benzodiazepines, H2 blockers, anticonvulsants. Request pharmacist review meds.

16. Assessment • Geriatric depression scale (GDS) for residents with MMSE (Mini mental state exam) greater than 15. • Cornell Scale for depression in dementia (CSDD): one of the best ways to screen for depression in nursing home residents. • Note: no screening test should be used in isolation. Screening should be targeted to high risk group. MDS is not sufficient in detecting depression in nursing home residents.

17. Assessment • In general, MMSE scores of 23-26 may be indicative of very mild dementia, 15-22 of dementia, 5-14 of moderate dementia, and less than 5 of severe dementia. • Clock drawing test: impaired in dementia but not in depression without dementia. • Score of greater than 8 on CSDD indicative of depression. • GDS: 5,10,15,30 item version. Different cutoffs.

18. Expert panel recommendation • Screening for depression 2-4 weeks following admission and repeated at least every 6 months. • New onset or worsening of symptoms should prompt an assessment that includes psychological, situational, and medical evaluations. • Residents with suicidal ideation (with or without a plan) should be immediately referred to a mental health professional.

19. Expert panel recommendation • Residents with psychotic symptoms and residents who have not responded to 6 or more weeks of treatment should be referred to a mental health professional. • Major depression: combination of drug and non-drug therapy. • Minor depression: meds only, non-drug interventions only and watchful waiting okay. • SSRIs first line antidepressants (citalopram [celexa], sertraline [zoloft]).

20. Team approach. • Primary care provider (physician, nurse practitioner, physician assistant). • Geriatric mental health provider. • Nurse, nurses aide. • Social worker. • Therapists (recreational, music, occupational, speech, nutritional). • Chaplain.

21. Goals • (1) improved mood/affect (eg smiling more, crying less). • (2) decreased depressive and anxiety symptoms (eg participating in activities, therapy, improved appetite, improved sleep). • (3) improved function (eg. dressing on their own, eating on their own). • (4) resolution of suicidal ideas.

22. Research: only a few studies. • Provision of pleasant activities improved depression in people with dementia. • Teaching caregivers problem solving skills improved depression in people with dementia. • Exercise for patients with dementia and depression combined with caregiver training improved depression.

23. Holistic approach. • Biopsychosocialspiritualcultural approach. • Individualized pleasant activity schedule (IPAS). • Music. • Funny movies/videos. • Sunshine / bright light therapy. • Animal/pet therapy. • Food. • Reminiscence • Intergenerational activity • Group.

24. ‘NO TEARS’ APPROACH • N = Nutritional interventions: favorite food, eating with family and friends, eating food high in inositol (naval oranges). • O = One to one interventions: listen to music together, hand massage, back rubs, conversation, reminiscence, visit life history book / memory book, watch TV together, sing and dance together, read a story / bible, going for walks together, color together, etc.

25. ‘NO TEARS’ approach • T = Technology based interventions: simulated presence therapy (audio or video recording of family and friends), use of internet (email, Legacy websites), ipod/mp3 to ensure list of favorite songs. • E = Environmental strategies: bring more sunshine in to the room, sit in the sun for 15-20 minutes a day, put flowers in the room, bright colored food plates, walk in a garden, go to a museum / zoo, go for a drive, go swimming, sit near a lake.

26. ‘NO TEARS’ approach • A = Animal assisted therapy: Bring pets (especially if history of having pets). Aromatherapy and Activities (group, structured and unstructured; cooking baking, cleaning, folding clothes, gardening, etc). • R = Reminiscence: memory book / life history book, old movies and discussion, etc. • S = Spirituality: listen to spiritual / religious songs, sing together, go to church more frequently, chaplain to talk regularly, etc.

27. ‘NO TEARS’ tool/rescue box. • List of favorite food items. • List of favorite one to one activities and topics of conversation get ‘hook’ the individual quickly. • DVD-movies, family videos, football games, favorite music CD, MP3/IPOD player. • Favorite lotions • Favorite poems, spiritual passages. • List of favorite places to go, favorite flowers, favorite family/friends to call.

28. 10 activities to enjoy a visit • Walk, exercise together. • Enjoy nature: sunshine, trees, birds. • Reminisce: photo albums, life story book. • Music: listen to CD, sing, dance. • Share personal life, talk about children, etc. • Painting: coloring together. • See movies, family videos, travel videos. • Touch: hold hands, massage, hugs and kisses. • Smile and laugh together, share jokes. • Eat together.

29. Validation therapy • Listening with empathy builds trust, reduces anxiety, and restores dignity. • People with dementia are in the final stage of life resolution and are trying to resolve unfinished life tasks, crises, or other business. • Painful feelings that are expressed, acknowledged and validated by a trusted listener will diminish; painful feelings that are ignored or suppressed will gain strength.

30. Minor and Major depression • Minor depression: non-drug interventions (such as individualized pleasant activity schedule) is best approach. • Major depression: combination of drug therapy and non-drug interventions is best recommended. • Treatment of pain is also key to successful outcomes.

31. Antidepressants • Older antidepressants: imipramine, amitriptyline, nortriptyline, doxepine. Generally avoided. • Newer antidepressants: sertraline (zoloft), citalopram (celexa), mirtazapine (remeron), duloxetine (cymbalta) generally recommended. May use venlafaxine (effexor) or escitalopram (lexapro). Some may need two antidepressants (eg citalopram and mirtazapine). Avoid paroxetine (paxil), fluoxetine (prozac) due to drug interactions.

32. Adverse effects • Older antidepressants: cognitive impairment, cardiac toxicity, hypotension, constipation. • Newer antidepressants: nausea, anorexia, vomiting, diarrhea. Small risk of low sodium (especially if person on diuretics), bleeding (especially if person on blood thinners) .

33. Antidepressants • Significant improvement in major depressive disorder symptoms and anxiety can be seen as early as week 1 or 2. Full antidepressant and anxiolytic effect may take 4 to 6 weeks.

34. Education and counseling • Education of patient/family. • Individual and caregiver: Problem solving therapy (especially for stress), cognitive behavior therapy (especially for recurrent depression), interpersonal therapy (especially for grief/bereavement). • Logotherapy (we can discover meaning in life in three different ways: by creating a work or doing a deed; by experiencing something or encountering someone; and by the attitude we take toward unavoidable suffering.

35. Referral to a psychiatrist • Suicide attempt. • Bipolar depression, schizophrenia, schizoaffective disorder. • Depression not responding to treatment within 3 months. • Depression with high medical complexity. • Depression in end-stages of life. • Depression with psychotic symptoms.

36. Bottom line • Depression is common in nursing home residents. Thus, maintain a high index of suspicion. • Depression causes immense suffering and decline in functioning. • Depression can be reliably differentiated from dementia. • Depression is eminently treatable. • Non-drug interventions are as critical as pharmacological interventions in treatment of depression in nursing home residents.