Wicking Dementia Research and Education Centre IS IT DEPRESSION, IS IT DEMENTIA OR BOTH? Dr Joanna Bakas Consultant Psychiatrist Dr Kate-Ellen Elliott Clinical Psychologist

Wicking Dementia Research and Education Centre 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

Wicking Dementia Research and Education Centre 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

Wicking Dementia Research and Education Centre 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

Wicking Dementia Research and Education Centre 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

Wicking Dementia Research and Education Centre Symptoms in common Amotivation Cognitive changes Worry about memory! Difficulty making decisions and problem solving Anxiety and agitation

Wicking Dementia Research and Education Centre Both occur due to changes in the brain Dementia Depression Changes in brain chemistry - – Serotonin – Norepinephrine – Dopamine

Wicking Dementia Research and Education Centre 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.

Wicking Dementia Research and Education Centre 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 9

Wicking Dementia Research and Education Centre 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 rd leading cause of mortality in Australia leading cause of disability for Australians 65 years + 10

Wicking Dementia Research and Education Centre 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 11

Wicking Dementia Research and Education Centre 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.

Wicking Dementia Research and Education Centre Depression in older adults Sub-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 13

Wicking Dementia Research and Education Centre WHY DISCUSS AT ALL? High rate of completed suicide in elderly Men - in 2011 – males per 100,000 vs – males in general 15.3 per 100,000 Women – female per 100,000 vs – females in general 4.8 per 100,000

Wicking Dementia Research and Education Centre 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

Wicking Dementia Research and Education Centre MANAGEMENT PRINCIPALS Multimodal Biopsychosocial approach Importance of careful assessment so an individualised treatment plan can be made Reassessment as things can change

Wicking Dementia Research and Education Centre DEPRESSION TREATMENT All the above relevant

Wicking Dementia Research and Education Centre 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.

Wicking Dementia Research and Education Centre 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).

Wicking Dementia Research and Education Centre 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

Wicking Dementia Research and Education Centre Social Issues/ Factors Housing Income / Employment Family problems Support network - relationships – quality over quantity Education

Wicking Dementia Research and Education Centre 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

Wicking Dementia Research and Education Centre 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

Wicking Dementia Research and Education Centre EARLY DEMENTIA Psychosocial 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

Wicking Dementia Research and Education Centre EARLY DEMENTIA Psychosocial 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

Wicking Dementia Research and Education Centre 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

Wicking Dementia Research and Education Centre 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

Wicking Dementia Research and Education Centre MODERATE - SEVERE DEMENTIA Psychosocial 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

Wicking Dementia Research and Education Centre MODERATE - SERVERE DEMENTIA Psychosocial 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.

Wicking Dementia Research and Education Centre 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)

Wicking Dementia Research and Education Centre 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

Wicking Dementia Research and Education Centre 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

Wicking Dementia Research and Education Centre 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

Wicking Dementia Research and Education Centre 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

Wicking Dementia Research and Education Centre 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

Wicking Dementia Research and Education Centre 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.

Wicking Dementia Research and Education Centre 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) Lifeline Better Access to Mental Heath Care Initiative