Understanding Depression and Dementia

1. UnderstandingDepression and Dementia Dr Maria-PalomaSequeiros 3/12/2013

2. Overview of Depression • Depressive disorders are common. • Lifetime prevalence may be as high as 30% in the general population. • Prevalence of 5-10% in primary care settings. • Women are twice as likely to be affected than men. • 4th cause of disability worldwide, may rank 2nd by 2020. • Although effective treatments are available, depression often goes undiagnosed and undertreated as symptoms are often regarded by both patients and doctors as “understandable” given current social circumstances and/or background.

3. Famous people who have had depression • Anthony Hopkins – actor • Audrey Hepburn – actress • Barbara Bush – former US First Lady • Claude Monet – artist • Cole Porter – musician • Elton John – musician • Ernest Hemingway – writer • Harrison Ford – actor • Jim Carrey – actor / comedian • Joan Rivers – comedienne • John Cleese – comedian • Judy Garland – actress • Laurence Olivier – actor • Marlon Brando – actor • Ozzy Osbourne – musician • Paul Simon – musician • Stephen Hawking – scientist • Yves Saint Laurent – fashion designer

4. Causes / Contributors for Depression • Functional brain changes: In older patients, hypoperfusion in frontal, temporal and parietal areas. • Neurotransmitter abnormalities: Reduced monoamine function may cause depression. Serotonine probably has an important role. • Genetic factors: Appear to influence the risk of developing depression by altering individual sensitivity to the effects of life stressors. • Personality / temperament factors: Certain temperaments (anxious, insecure) may increase vulnerability to depression. • Psychological factors: Disruption of normal social, marital, parental, or familial relationships is correlated with high rates of depression, and is a risk factor for recurrence. Low self-esteem is proposed as a vulnerability factor. • Social factors: People of low socio-economic status are at demonstrable higher risk of depression. Social causation: stress associated with such problems leads to depression.

5. Risk factors for Depression • Genetic: Heritability estimates range from 40-70%. • Childhood experiences: Loss of a parent, lack of parental care, parental alcoholism / antisocial traits, childhood sexual abuse, traumas. • Personality traits: Anxiety, impulsivity, obsessionality. • Social circumstances: Marital status (separated/divorced or widowed), unemployment / financial difficulties, adverse life events (losses), loneliness / isolation, lack of social support. • Physical illness: Especially if chronic, severe or painful, affecting mobility and independence.

6. Symptoms of Depression (1) • Depressed mood present most of the day, nearly every day, with reduced emotional reactivity – for at least 2 weeks representing a change from normal • Mood may be worse in the morning, improving as the day progresses • Tearfulness • Anhedonia: Markedly diminished interest or pleasure in all, or almost all activities. • Decreased or increased appetite associated with weight loss or gain • Disturbed sleep: Insomnia with early morning wakening or hypersomnia. • Psychomotor agitation or retardation observed by others • Fatigue or loss of energy • Lack of initiative and motivation

7. Symptoms of Depression (2) • Diminished ability to think or concentrate or indecisiveness • “Pseudodementia”: Memory and concentration problems simulating dementia that improve with mood improvement. • Anxiety • Constant worrying • Reduced self confidence • Irritability, impatience • Social withdrawal and tendency to self isolate • Decline in normal functioning / abilities • Disregard for personal care

8. Symptoms of Depression (3) • Somatic complaints: Unspecific aches and pains, gastro-intestinal upset, headaches, complex physical sensations • Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) • Negative and pessimistic thinking • Hopelessness • Recurrent thoughts of death or suicide which may or may not be acted upon • Delusions: Poverty, personal inadequacy, guilt over presumed misdeeds, responsibility for world events (accidents, natural disasters, wars), deserving of punishment, nihilistic delusions • Hallucinations: Auditory, visual, olfactory, tactile

9. Course of Depression (1) • Depressive episodes vary from 4-30 weeks for mild / moderate cases. • Severe cases last an average of 6 months with 25% lasting up to a year. • 10-20% of patients have a chronic course with persistent symptoms lasting over 2 years. • Late onset depression may be more chronic and is more likely to be associated with life events. • The majority of patients experiencing a depressive episode will have further episodes in life. • Risk of recurrence is 30% at 10 years, 60% at 20 years. • Risk of recurrence is greater when there are residual symptoms after remission (about 1/3 of cases) such as low mood, anxiety, sleep disturbance, and physical symptoms (headache, fatigue, gastrointestinal complaints).

10. Course of Depression (2) • There is good evidence that modern antidepressant treatments reduce the length of depressive episodes. • If treatment is given long term, the incidence of residual symptoms is less, there are fewer recurrent episodes, and chronicity may be as low as 4%. • Good prognostic indicators for older people: • Onset before age 70 • Short illness • Good previous adjustment • Absent physical illness • Good previous recovery • Poor outcome in the elderly is associated with: • Severity of initial illness • Psychotic symptoms • Physical illness • Poor medication compliance • Severe life events during follow-up period

11. Treatments for Depression – Antidepressants (1) • Work by correcting neurotransmitter abnormalities? • Effective in 65-75% of patients. • The choice of a specific antidepressant depends on: • Patient factors: Age, comorbid physical illness (cardiac, renal, liver, neurological), previous response to antidepressants • Issues of tolerability: Different antidepressants have different side-effect profiles • Symptomatology: Sleep problems (more sedative agent), lack of energy (more stimulatory agent), OCD symptoms (drug more effective for OCD), risk of suicide (safer drugs on overdose)

12. Treatments for Depression – Antidepressants (2) • Antidepressant effect may take up to 3 weeks. • Adequate trial of an antidepressant is at least 6 weeks of the highest tolerated dose. • Failure of an adequate trial of antidepressant treatment may occur in around 25% of cases. • About 25% of patients will experience unacceptable side-effects (genuinely drug-induced, due to anxiety, psychosomatic, psychological) leading to withdrawal of the agent without completing an adequate trial. • For these patients, second-line treatment is with an alternative antidepressant usually from a different class or from the same class but with a different side-effect profile.

13. Treatments for Depression – Antidepressants (3) • Compliance with medication treatment is encouraged even when feeling “better”. • Effective treatment should continue for 6-12 months after remission, particularly if there are residual symptoms. • If period between episodes is less than 3 years, or with severe episodes (marked suicidal thoughts / actions), prophylactic treatment should be maintained for at least 5 years – often indefinitely. • There is no evidence of any specific problems with long-term antidepressant use.

14. Treatments for Depression – Antidepressants (4) • Antidepressants can de used in combination. • Anxiolitics can be used to help with anxiety features and sleep. • Other drugs such as antipsychotics and mood stabilisers can be used. • The combination of pharmacotherapy and psycho-social approaches is probably more effective than only medication treatment. • Hospital admission may be needed to minimise risks (of self harm, self neglect, harm to others), for close monitoring of medication treatment, for initiation of ECT.

15. Treatments for Depression – ECT • The specific mode of action of ElectroConvulsive Therapy treatment is unknown. • ECT causes a wide range of effects on all neurotransmitters and on the neuroendocrine system. • Advances in brief anaesthesia and neuromuscular paralysis have led to improved safety and tolerability. • Contraindications include recent MI, cardiac problems, cerebral aneurysm / haemorrhage, retinal problems, anaesthetic risk. • ECT is a highly effective (and controversial) treatment for depression, especially depression with psychotic symptoms. • It may act more quickly than antidepressant treatment. • ECT may be indicated in severe episodes, need for rapid antidepressant response (failure to eat / drink, depressive stupor), drug treatment failure, intolerability to drug treatments, previous history of good response to ECT, patient preference.

16. What is Dementia? • Dementia is an unspecific term used to describe the symptoms that occur when the brain is affected by degenerative diseases and conditions, such as Alzheimer's disease. • Dementia affects the person’s cognitive function that includes: • memory • attention and concentration • language • visuo-spatial abilities • ability to plan and solve problems • Dementia is progressive, which means the symptoms will gradually get worse. How fast dementia progresses will depend on the individual. • The way in which the person’s brain is affected by dementia differs from person to person, so each person experiences dementia in their own unique way.

17. What causes Dementia? • Alzheimer's dementia: The most common cause of dementia. During the course of the disease the chemistry and structure of the brain changes, leading to the death of brain cells. Generally global gradual cognitive decline with short term memory loss, disorientation, language and functional difficulties. • Vascular dementia: The brain relies on a network of vessels to bring it oxygen-bearing blood. Brain cells are likely to die when the oxygen supply to the brain fails, and this can cause the symptoms of vascular dementia. These symptoms can occur either suddenly, following a stroke, or over many years, due to a series of small or micro strokes. Deterioration can be step-wise with ‘patchy’ cognitive deficits. • Lewy-body dementia: This form of dementia shares some characteristics with Parkinson's disease. It gets its name from tiny spherical structures that develop inside nerve cells. Their presence in the brain leads to the degeneration of brain tissue. Presentation can fluctuate from day to day with the presence of visual hallucinations. • Fronto-temporal dementia: In fronto-temporal dementia, damage is usually focused in the front part of the brain. Personality changes and abnormal behaviours (lack of initiative / motivation, excessive drive / disinhibition) may be more prominent than memory problems. • Mixed dementia: Multiple causes.

18. Who gets Dementia? • There are about 700,000 people in the UK with dementia. • Dementia affects men and women. • Dementia mainly affects older people. However, it can affect younger people: there are 15,000 people in the UK under the age of 65 who have dementia. • Scientists are investigating the genetic background to dementia. It does appear that in a few rare cases the diseases that cause dementia can be inherited, and that some people with a particular genetic make-up have a higher risk than others of developing dementia.

19. Symptoms of Dementia (1) • Loss of memory: Forgetting what happened a few minutes ago, earlier the same day, yesterday or a week ago. Also, forgetting what happened in the past. Disorientation to place: getting lost at home or forgetting the way home from the shops. Disorientation to time: not knowing the time of the day, the day of the week, the month, the year. Being unable to remember words, names and places. • Mood changes: People with dementia can feel anxious, frustrated, worried, sad, frightened or angry. Mood symptoms may be particularly manifest if parts of the brain that control emotion are affected. Low mood may be a psychological reaction to not being able to understand what is going on around you, or it can be linked to having insight into your functional inabilities and loss of independence. • Communication problems: Difficulties comprehending language and expressing yourself. A decline in the ability to talk, understand, read and write.

20. Symptoms of Dementia (2) • Behavioural disturbance repetitive behaviours shouting and screaming restlessness agitation aggression passivity lack of initiative and motivation loss of interest in things disinhibition socially/sexually inappropriate behaviours obsessional behaviours hoarding checking hiding and losing things suspicion paranoia delusions hallucinations (visual and auditory) night-time waking poor sleep at night activity at night excessive sleeping during the day inactivity during the day poor appetite and loss of interest in food (with weight loss) excessive eating (especially sweet things) visuo-spatial difficulties

21. Symptoms of Dementia (3) • Lack of insight into cognitive deficits and behavioural disturbance: “My memory is fine!”, “There is nothing wrong with me”, “I can take care of myself”, “I do everything myself”, “I don’t need any help!”. Linked to memory loss, urge to maintain level of independence and dignity, and pre-morbid personality traits. The person with dementia may be reluctant to accept practical help, medical and nursing input, or to comply with treatments that are offered (including refusing to take medication). • In the later stages of dementia, the person affected will have problems carrying out everyday tasks, and will become increasingly dependent on other people. The person’s mobility may also be affected.

22. Treatment for Dementia • Dementia cannot be cured, although research is continuing into developing drugs, ‘vaccines’ and treatments. Drugs have been developed that can temporarily alleviate some of the symptoms of some types of dementia. These drugs are known as acetylcholinesterase inhibitors or anti-dementia drugs. • The National Institute for Health and Clinical Excellence (NICE) recommends that people in the moderate stages of some types of dementia – Alzheimer's dementia and Lew-body dementia – should be given treatment with an anti-dementia drug. • People with dementia who develop anxiety disorders, depression, behavioural problems such as restlessness or aggression, significant sleep disturbance, or psychiatric symptoms such as psychosis (delusions and hallucinations), may be prescribed drugs to treat these symptoms.

23. ANY QUESTIONS?

24. NICE (National Institute for Health and Clinical Excellence 2009) in guidance helps health and social care professionals deliver the best possible care based on the best available evidence. Treatment and care should take into account people’s individual needs and preferences. GP Refer moderate/severe depression Refer mild/moderate depression CIT Team LIFT (Least Intervention First Time) Community Psychiatric Nurse Doctor CIT Team Roles Support Worker Psychologist OccupationalTherapist Physiotherapist