27/02/16

1

1

UE1.2.4

Spécificités des méthodes et outils d’évaluation

Dépression / Apathie Diagnostic / Evaluation

2

PART1dADpatients-Whoarethey?dAD:DepressionofAlzheimer‘sDisease

3

dADpatientsWhoarethey?

Depressioninoldage:generalconceptDepressionasoneneuropsychiatricsymptomofdementiaDiagnosisofdepressioninAD

PharmacologicaltreatmentofdepressioninAD

1

2

3

4

27/02/16

2

4

Depressioninoldage:generalconcept

1

5

TheClassicalDepressiveSymptomsaccordingtoDSM*

1

*clinicallysignificantimpairmentinsocial,occupationalorotherfunctioningminimum5symptomspresentduringthesame2-weekperiod(oneiseitherdepressedmoodorlossofinterest

Othersomaticcomplaints

Anxiety

AgitationorRetardation

Sleepdisorders Fatigue

Lossofenergy

Pessimistic

Concentratingdifficulty

IndecisivnessDepressedmoodLossofpleasure Irritability

Lowselfesteem

FeelingofWorthlessness

orguilt

Hopelessness

Significantweightlossorweightgain

SocialisolationWithdrawal

Decreaseorincreaseofappetite

RecurrentthoughtofdeathSuicideideationorattempts

Coresymptoms

Typicalsymptoms

Associatedsymptoms

DSM

-V

6

Depressionintheelderly1

•  Fullycharacterizedmajordepressionislesscommonthandepressive

symptoms,whichareasfrequentasinearlierlife

•  Depressedmoodmaynotbethemajorcomplaint

•  Somatic(e.g,pain)andcognitivecomplaintsmaydominate

•  Anxiety,irritabilityandapathyaremorefrequentthaninearlierlife

27/02/16

3

7

DepressionasoneneuropsychiatricsymptomofDementia

2

DepressionasoneneuropsychiatricsymptomofDementia

2

CognitiveSymptomsMemoryLanguageAttentionApraxia

Non-Cogni(veSymptomsApathy

DepressionAgita>on

Psycho>csymptoms

LossofAutonomyinActivitiesofDailyLivingIncreaseinCaregiverBurden

9

DepressioninAD2

•  Verycommon:Prevalenceof77%overa5-yearperiod*

•  Oftenassociatedwithapathyandincreaseinirritability

•  Noclearassociationbetweendementiaseverityanddepression

•  Increasestheburdenofbothpatientsandcaregivers

•  Isassociatedwithagreaterdeclineinqualityoflife**

•  Earlierinstitutionalization**

•  Increasedriskofmortality**

•  Hasasignificanteconomicimpact*Steinbergetal.,2008;**LyketsosCGetal.,2002;Fernández-Martínezetal.,2008

27/02/16

4

Prevalenceofneuropsychiatricsymptomsovera5-yearperiod

Five-year prevalence of NPI symptoms (NPI >0) in the Cache County Study (Steinberg et al., 2008).

2

408patients:63%AD11%VaD6%mixed20%otherdementias>65yearsold

11

SeverityofADandprevalenceofdepression2

N=499ADpatientsREAL.Frstudy,Benoit&al;RevMedInt,2003

12

DepressioninAlzheimer’sDisease2

minimum3symptomspresentduringthesame2-weekperiod(oneiseitherdepressedmoodordecreasedpleasureinresponsetousualactivities)

Irritability

Sleepdisorders

FatigueLossofenergy

Dementia Depressed mood

Decreased pleasure in response

to usual activities Feelingof

worthlessness

Disruptioninappetite

SocialisolationWithdrawal

Psychomotorchanges

Thoughtsofdeath

27/02/16

5

13

2 DepressioninAD≠depressioninelderly

dAD DepressioninelderlyHigherfrequencyofMotivationalDisturbancessuchas: fatigue

psychomotorslowing

apathy

HigherfrequencyofMoodSymptomssuchas: depressedmood

anxiety

suicidality

sleepand

appetitedisturbances

14

DiagnosisofdepressioninADandoverlaps

3

15

DiagnosisofdepressioninAD3

•  Inclinicalpractice,diagnosisofdepressioninADincludes:•  areviewofpatient‘smedicalhistory•  aphysicalexamination•  acognitiveexamination•  abehaviouralexaminationincludingsuicidalideation•  interviewswithfamilymembers(informants)*

• ProvisionalNIMHDiagnosticCriteriaforDepressionofADusedtodefinepatientswithADanddepression

• Ratingscalesappropriateformeasuringeffectsofastudydruginaclinicaltrialwithdementedpatients:NPIandCSDD

*www.alz.org/care/alzheimers-dementia-depression.asp;Tengetal.,2008

27/02/16

6

16

NIMH-dAD(1/2)3A.Three(ormore)ofthefollowingsymptomsmustbepresentduringthe

same2-weekperiodandrepresentachangefrompreviousfunctioning.

Atleastoneofthesymptomsmusteitherbeeither1.or2.1.Clinicallysignificantdepressedmood2.Decreasedpositiveaffectorpleasureinresponsetosocialcontactsand

usualactivities3.Socialisolationorwithdrawal4.Disruptioninappetite5.Disruptioninsleep6.Psychomotorchanges7.Irritability8.Fatigueorlossofenergy9.Feelingsofworthlessness,hopelessness,orexcessiveorinappropriateguilt10.Recurrentthoughtsofdeath,suicidalideation,planorattempt

AdaptedfromOlinetal.2002

17

NIMH-dAD(2/2)3

AdaptedfromOlinetal.2002

B.AllcriteriaaremetforDementiaoftheAlzheimerType(DSM-IV-TR)

C.Thesymptomscauseclinicallysignificantdistressordisruptioninfunctioning

D.Thesymptomsdonotoccurexclusivelyinthecourseofdelirium

E.Thesymptomsarenotduetothedirectphysiologicaleffectsofasubstance

F.Thesymptomsarenotbetteraccountedforbyotherconditionssuchasbereavement,psychosisofAlzheimerdiseaseorsubstance-relateddisorders

ThebaselinefrequencyofdepressionusingNIMH-dADcriteria(44%)washigherthanthatobtainedusing:-DSM-IVcriteriaformajordepressionorminordepression-establishedcut-offsfortheCSDD-GDS

• NIMH-dADcriteriacorrectlyidentifiedallpatientsmeetingDSM-IVcriteriaformajordepression• NIMH-dADcorrelatedwellwithDSM-IVcriteriaformajororminordepression• 94%sensitivityand85%specificityConclusionsTheNIMH-dADcriteriaidentifyagreaterproportionofADpatientsasdepressedthanseveralotherestablishedtools.

3

Teng et al., 2008

NIMH-dAD(Results)

27/02/16

7

19

Difficultiesencounteredindailyclinicalpractice

3

DifferentiatingbetweendepressioninADanddelirium(e.g.ifleadingsymptomsare:agitation/retardation;cognitiveworsening)

DifferentiatingbetweendepressioninADandapathyinAD(e.g.ifleadingsymptomsare:lossofdrive,lossofemotion,lessgoal-directedcognition)

Difficulties§  Patient'slossofinsight/difficultyarticulatingsymptomsduetodementia§  Caregivermaythemselvesbedepressedduetothedailyburden*§  Concomitanttreatment(e.g.sedation,restlessness,blurredsymptomatology)

*MacKenzieTBetal,AmJPsychiatry,1989.

Diagnosticcriteriaforapathy

3

!Lossofordiminishedmotivationincomparisontothepatient’spreviousleveloffunctioningandwhichisnotconsistentwithhisageorcultureforatleast4weeks

!Thesechangesinmotivationmaybereportedbythepatienthimselforbytheobservationsofothers

!Lossof,ordiminished(min2/3features)•  goal-directedbehaviour•  goal-directedcognitiveactivity•  interest•  emotion

20

DepressioninAD–Apathy

Apathy:motivationaldisturbanceDepression:emotionaldisturbance

Diminishedmotivation(alsotodothingsusuallyfoundenjoyable)BluntedEmotion

DepressedMoodInabilitytoexperiencepleasurefromactivitiesusuallyfoundenjoyable(Anhedonia)

FatigueWithdrawal

LossofinterestCognitiveworseningIrritability

3

21

27/02/16

8

Benoitetal.,2012:N=734;Age=80±6.6years;M/F=38/62%;MMSE=23.1±2.2

DepressionD

iagnosis

ApathyDiagnosis

3 DepressioninAD–Apathy

23

TreatmentofdepressioninAD

4

!NodrugcurrentlyapprovedbyregulatoryagenciesforthetreatmentofdepressivesymptomsinAD

!DIADS-2 study (RCT, sertraline vs placebo; n=131): n.s. symptomchanges,responseandremissionrates

!HTA-SADDstudy(RCT,sertraline,mirtazapine,placebo;n=326):n.s.

!If a patient presents with antidepressant medication it may havebeenprescribedfortreatmentofanxietyingeneralpractice

!Treatment of depression associated with improved cognitiveperformance

Rosenbergetal,2010;Banerjeeetal.,2011;Leong,2014RCT:RandomisedClinicalTrial

4 PharmacologicalTreatmentofdAD

24

27/02/16

9

!Occupational therapyhas shown to reducebehavioral symptoms inADincludingdepressionandtoimproveactivitiesofdailyliving

!Animal-assisted therapyhas been shown to be effective in treatingapathy, agitation and depression in AD as well as deficits incommunicationandsocialinteraction

!Reminiscence therapy in combination with productive activitysignificantlyreducesdepressioninpatientswithAD

e.g.Holthoffetal.,2013;Bernabeietal,2014;Nakamaeetal,2014

4 Non-PharmacologicalTreatmentofdAD

25

26

Conclusions

Depressionisanemotionaldisturbanceandhighlydisablinginoldage.DepressioninADjeopardizesADLandpromotesinstitutionalization.Apathyisamotivationaldisturbanceoftenencounteredindementiaandmaybemistakenasdepressivesymptom.DepressioninADisdifficulttomanageasthereislackofeffectivepharmacologicaltherapy.Itisnecessarytosearchforanewtreatmentstrategy.

123

4

27

PART2AssessmentofdepressivesymptomsindADpatients

27/02/16

10

28

AssessmentofdepressivesymptomsindADpatients

Differenttypesofassessment(GDS,NPI,CSDD…)NeuropsychiatricInventory(NPI)CornellScaleforDepressioninDementia(CSDD)

1

2

3

Differenttypesofassessment

Thepointofviewof

TheClinician+-

MADRSCSDD

ThePatient+-GDS

TheCaregiver+-NPI

1

29

§ Delusion§ Hallucination§ Agitation§ Depression§ Anxiety§  Euphoria§ Apathy§ Disinhibition§  Irritability§ Aberrantmotorbehaviour§  Sleepproblems§  Eatingproblems

NeuropsychiatricInventory(NPI)domainsscores

ForeachdomainFrequencyxSeverityisscoredbymultiplyingseverity(1-3)byfrequency(1-4)

FxS from range 0 - 12

2

30

27/02/16

11

NPI–Dysphoriadomain(1/2)

Does(S)seemsadordepressed?Does(S)saythathe/shefeelssadordepressed?(P)Yes:£No:£Responsesshouldbebasedonthepast4weeks.CaregiverInterview*Frequency0-4Severity0-3 31

2

NPI–Dysphoriadomain(2/2)

1.Does(S)haveperiodsoftearfulnessorsobbingthatseemtoindicatesadness?

2.Does(S)sayhe/sheissadorinlowspiritsoractsasifhe/sheissadorinlowspirits?

3.Does(S)puthim/herselfdownorsaythathe/shefeelslikeafailure?

4.Does(S)seemverydiscouragedorsayhe/shehasnofuture?

5.Does(S)sayhe/sheisaburdentothefamilyandthatthefamilywouldbebetteroffwithouthim/her?

6.Does(S)expressawishfordeathortalkaboutkillinghim/herself?

7.Does(S)saythathe/sheisabadpersonanddeservestobepunished?

Does(S)seemsadordepressed?Does(S)saythathe/shefeelssadordepressed?(P)Yes:£No:£

2

32

CornellScaleforDepressioninDementia(CSDD)(1/2)MoodRelatedSignsAnxietySadnessLackofreactivitytopleasantevents:IrritabilityBehavioraldisturbancesAgitationRetardationMultiplephysicalcomplaints:Lossofinterest

IdeationalDisturbanceSuicideSelf-depreciationPessimismMood-CongruentDelusionsPhysicalSignsAppetiteLossWeightLossLackofenergyCyclicFunctionsDiurnalvariationofmoodDifficultyfallingAsleepMultipleawakeningsduringsleepEarlyMorningawakenings

3

33

27/02/16

12

Theclinicianratingisbasedonallavailableinformationcomingfromthepatient,caregiverinterviewandanyadditionalmaterials(e.g.,chartnotes)

§ SCORINGSYSTEMü 0=absentü 1=mildtointermittentü 2=severeü 9999=unabletoevaluate

3

34

CornellScaleforDepressioninDementia(CSDD)(2/2)