The diagnosis and treatment of depression in dementia

Design, synthesis and evaluation of vilazodone-tacrine hybrids as multitarget-directed ligands against depression with cognitive impairment

Depression, a severe mental disease, is greatly difficult to treat and easy to induce other neuropsychiatric symptoms, the most frequent one is cognitive impairment. In this study, a series of novel vilazodone-tacrine hybrids were designed, synthesized and evaluated as multitarget agents against depression with cognitive impairment. Most compounds exhibited good multitarget activities and appropriate blood-brain barrier permeability. Specifically, compounds 1d and 2a exhibited excellent 5-HT_1A agonist activities (1d, EC₅₀ = 0.36 ± 0.08 nM; 2a, EC₅₀ = 0.58 ± 0.14 nM) and 5-HT reuptake inhibitory activities (1d, IC₅₀ = 20.42 ± 6.60 nM; 2a, IC₅₀ = 22.10 ± 5.80 nM). In addition, they showed moderate ChE inhibitory activities (1d, AChE IC₅₀ = 1.72 ± 0.217 μM, BuChE IC₅₀ = 0.34 ± 0.03 μM; 2a, AChE IC₅₀ = 2.36 ± 0.34 μM, BuChE IC₅₀ = 0.10 ± 0.01 μM). Good multitarget activities with goodt blood-brain barrier permeability of 1d and 2a make them good lead compounds for the further study of depression with cognitive impairment.

Dementia

Dementia is a syndrome seen most commonly in older people and characterized by a decline in cognitive performance which impacts on the person's ability to function. There are approximately 47 million people worldwide with dementia and there are 10 million new cases every year. It is a major cause of disability and dependence and impacts on the physical, psychologic, and social well-being of families and carers. Alzheimer's disease is the most common form of dementia. Gait and balance impairments are common in people with dementia and contribute to the significantly elevated risk of falls. Older people with dementia are at increased risk of injury, institutionalization, hospitalization, morbidity, and death after a fall. There is preliminary evidence, predominantly from relatively small studies, that falls and disability can be prevented in this population. However, more good-quality research is needed, both to provide some certainty around the existing evidence base as well as to explore alternate approaches to prevention, including combined cognitive-motor training and cognitive pharmacotherapy.

Measuring psychological well-being in cognitively impaired persons

An objective measure of psychological well-being (a previously understudied outcome for persons with dementia) was developed and tested as part of a longitudinal study ( n= 96 participant pairs; n= 73 pairs remaining at 18 months). The reliability and validity of the Psychological Well-being in Cognitively Impaired Persons (PWB-CIP) scale was examined as a measure of one dimension of quality of life (QoL) as persons progress in the disease. The original 16-item PWB-CIP Likert-type scale required only five to 10 minutes to complete and was reduced to 11 items following factor analysis. Cronbach's alpha for the total scale was .79 at baseline and .82 at 18 months. Two subscales were identified: positive affect/interaction and negative affect/interaction. One item ('involved in a single activity for > five minutes') loaded on a different subscale at baseline (early disease stages) compared to 18 months (reflecting disease progression). The internal consistency of the two subscales remained acceptable across the two measurement intervals. Controlling for mental status, the PWB-CIP's construct validity was supported through significant relationships with depression, personal characteristics (personality), and the behavioral competence QoL dimensions at baseline and at 18 months. Because both rural (55%) and urban populations were sampled and the PWB-CIP was used across care settings, the findings support the PWB-CIP as a psychometrically sound measure of psychological well-being for diverse populations of persons with dementia.

A Person-Centred Approach to Counselling, Psychotherapy and Rehabilitation of People Diagnosed with Dementia in the Early Stages

This article considers a person-orientated approach to counselling, psychotherapy and rehabilitation for people with a diagnosis of dementia. It draws on the concepts developed by Tom Kitwood (1995) for describing the factors –neuropathology, health, personality, biography, social psychology – that affect the manifestation of dementia, but places more emphasis on personality and biography for the person in the early stages. The social context – or psychology – is the home in these early stages, and the family system is critical. It provides a supportive or negative environment in which the person expresses an experience of cognitive decline. The behaviours seen in dementia are regarded as adaptive responses to the experience of cognitive decline, rather than directly the result of brain pathology. Given this view of the syndrome of dementia being a reactive response to cognitive decline, and to stresses such as giving up driving, the types of interventions that might be offered are discussed. These are grief counselling, non-directive counselling, long-term supportive psychodynamic psychotherapy, cognitive-behavioural therapy and rehabilitation. The human brain has developed over a lifetime of experience, in a variety of psychosocial environments, and so exhibits its own unique coping mechanisms in the face of internal devastation. It is this aspect of dementia – its individual uniqueness and its reflection of a person’s past and present psychosocial context – that this article uses as the basis for suggesting effective treatment strategies.

Managing falls in older patients with cognitive impairment

With an aging population, both dementia and fall-related injury pose an international health challenge. Individuals with dementia fall twice as often as cognitively intact people and are more likely to have injurious falls. Higher morbidity and rates of mortality and institutionalization after falls have also been reported in this group. There is limited but emerging literature that is attempting to define and explain why fall risk is increased in this population. This will allow for targeted fall prevention programs. Currently, there are no published randomized controlled trials that have prevented falls in community-dwelling cognitively impaired older people, and conflicting evidence is reported in hospital and residential care trials. Recent exercise interventions have demonstrated significant benefits, such as improved gait speed, strength and balance in people with cognitive impairment/dementia, providing encouraging evidence for further research and clinical interventions.

Depression in Taiwanese patients with Alzheimer's disease determined by the National Institutes of Mental Health Provisional Criteria

BACKGROUND

Depression is a common behavioral and psychological symptom of Alzheimer's disease (AD). The aims of the present study were to determine the rate of depression in Taiwanese patients with AD using the National Institutes of Mental Health Provisional Criteria for Depression in AD (NIMH-dAD criteria) and to investigate the association of depression with other behavioral and psychological symptoms.

METHODS

A consecutive series of 302 AD patients registered in a dementia clinic were investigated in this study. All patients met the criteria of the National Institute of Neurological Disorders and Stroke-Alzheimer's Disease and Related Disorders Association for probable AD. The rates of depression were determined according to the criteria of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders for major depression (DSM-IV), the International Classification of Diseases-9-Clinical Modification (ICD-9-CM) for neurotic depression, the depression subscale of the Neuropsychiatric Inventory (NPI), and the NIMH-dAD criteria. Depression severity was assessed using the 17-item Hamilton Depression Rating Scale. The rates of depression determined by the NIMH-dAD criteria were compared with the rates derived from each of the other instruments. Other behavioral and psychological symptoms were assessed using NPI. A behavioral neurologist or a geriatric psychiatrist interviewed all the patients.

RESULTS

Using the NIMH-dAD criteria, it was found that 90 (29.8%) of the AD patients had depression, and all depressive symptoms in NIMH-dAD were significantly higher among depressed patients. Among other depression instruments, the frequency of depression was lowest using the DSM-IV major depression criteria (9.3%) and highest with the NPI depression subscale (54%). Behavioral and psychological symptoms determined with NPI were significantly higher among depressed patients in all domains except euphoria.

CONCLUSIONS

This is the first study of depression in Taiwanese patients with AD using the NIMH-dAD criteria. Our findings suggest that comorbid depression is high in Taiwanese patients with AD. It is clinically important to note the high frequency of most behavioral and psychological symptoms among depressed AD patients.

A useful and brief cognitive assessment for advanced dementia in a population with low levels of education

BACKGROUND/AIMS

Almost half of community-dwelling patients and 59.6% of institutionalized residents with dementia are in moderate or severe stages of this disease. The Mini-Mental State Examination (MMSE) has limited applicability to these patients due to floor effects. We aimed to determine the correlation between the MMSE and the Severe Mini-Mental State Examination (SMMSE), as well as SMMSE association with functional scales in patients having moderate to severe dementia and low levels of education.

METHODS

A cross-sectional study of patients 60 years or older attending an outpatient clinic was conducted. The MMSE, SMMSE and functional scales were applied. Clinical and demographic data from medical records were reviewed.

RESULTS

Seventy-five patients with a mean of 4.1±3.6 years of education were analyzed. The mean scores on the MMSE and SMMSE were 7.8±7.0 and 17.8±9.4, respectively. The results indicated that the MMSE and SMMSE correlated only in patients who had an MMSE score of less than 10 (r=0.87; p<0.001). In addition, significant correlations were found between the SMMSE and functional scales (p<0.001). It was observed that educational level did not interact with SMMSE performance.

CONCLUSION

The SMMSE is a useful and reliable tool for a brief cognitive assessment of advanced dementia patients with low educational levels.

Predictors of quality of life for individuals with dementia

Although a growing number of investigations examine the lived experience of individuals with dementia (IWDs), few draw upon a conceptual model to explore inter-relationships among background characteristics, stressors, and outcomes (Menne, 2006). This study is guided by a conceptual model that draws upon the broader stress literature to examine predictors of IWD quality of life. Relying primarily on IWD self-reported data (n = 211), multivariate ordinary least squares regression analysis was used to determine the predictors of IWDs’ quality of life. Results indicate that IWDs who report poorer quality of life are more likely to be African-American, have a non-spousal caregiver, have more depressive symptoms, be less involved in daily decision-making, and have more negative strain with their caregiver. These findings are discussed in the context of current and practical interventions that address the strengths and needs of IWDs and their family caregivers.

Depression among newly admitted Australian nursing home residents

BACKGROUND

This research concerns the prevalence and course of depression in newly admitted nursing home residents. We attempted to recruit consecutive admissions into the study, irrespective of cognitive status, enabling a comparison of the prevalence and course of depression experienced by cognitively intact residents and those exhibiting all levels of cognitive impairment.

METHOD

Depression was assessed at one month, three months and six months post-admission. The assessment of mood in this study entailed the conduct of a semi-structured clinical interview, which encompassed DSM-IV criteria and Cornell Scale for Depression in Dementia (CSDD) items.

RESULTS

Recruitment difficulties resulted in a sample of 51 newly admitted residents, drawn from six nursing homes located in Victoria, Australia. Of particular interest, throughout the duration of the study, only the cognitively impaired were diagnosed with major depression (MD). One month post-admission, 24% of the sample were diagnosed with MD, and a further 20% evidenced a non-major depressive disorder. At the second and third assessments, MD was observed in 14% and 15% of residents, respectively. For residents who completed all three assessments, there was no appreciable change in the proportion diagnosed with a depressive disorder, nor was there a change in the levels of depressive symptomatology.

CONCLUSION

Although subject to limitations, the current study indicated that clinical depression in nursing home facilities most often occurs in residents who also exhibit pronounced cognitive impairment. These depressions are unlikely to remit spontaneously. Accordingly, care staff and general practitioners must be trained in the identification of depression in dementia, and any interventions implemented in these facilities should be tailored to meet the unique needs of this group.

Vocally disruptive behaviour in dementia: development of an evidence based practice guideline

Vocally Disruptive Behaviour (VDB) is a term that includes screaming, abusive language, moaning, perseveration, and repetitive and inappropriate requests. It is one of the most challenging behaviours for nursing home staff, caregivers for people with dementia, and other nursing home residents. As with other behavioural disturbances, multiple causal factors have been identified in the literature and individual cases may have a number of interacting factors. There is a lack of consensus about how to treat VDB. Systematic treatment studies are few and there is a lack of empirical data supporting the effectiveness of specific interventions commonly used in clinical practice. This hinders clinicians and may result in the use of inappropriate treatments. Our aim was to systematically review the literature in order to develop a practice guideline for the assessment and management of VDB. The review will examine the typology, risk factors and management of VDB.

Complexity in late-life depression: impact of confounding factors on diagnosis, treatment, and outcomes

Late-life depression is a heterogeneous syndrome. Although depression in elderly patients is highly treatable, a number of factors or confounds create complexity in its overall management. Patient factors, such as medical illness, neuropsychiatric comorbidity, and race, may interact with provider factors to make management more complex. Outcomes and services research indicate that these factors, particularly medical illness, affect whether late-life depression is appropriately detected, diagnosed, and treated. Attention to such factors must be included in an agenda for mental health services research, with emphasis on the delivery of effective treatment to elderly patients with depression and improved outcomes in clinical settings.