Preventing depression & promoting well-being in early

stage dementia

Senior Fellow of the Alzheimer's Society, & Senior Research Associate, UCL

Dr Vasiliki Orgeta

Prevalence of depression in dementia

- Ranges from 0-86%

- Systematic review - Alzheimer's disease (Chi et al., 2015)

- DSM criteria for major depression - 12.7%

- AD specific criteria - 42%

- Screening tools - 6% to 36%

Prevalence of depression in AD

Assessment

method

Major

(DSM)

Minor

(DSM)

Dysthy

mia

(DSM)

ICD NPI PDC-

dAD

CERAD-

BRS

CUSPA

D

ADAS--

NonCog

GDS HADS

≥16

CSDD

≥7

CSDD

≥8

CSDD

≥13

Prevalence

%

(95% CI)

12.7(8-17)

27(18-39)

19(12-30)

16(8-31)

41(37-45)

40(30-51)

67(41-86)

42(38-46)

33(38-46)

33(29-36)

6(4-9)

29(25-34)

36(24-49)

17(8-34)

N of studies 25 3 5 4 19 5 2 2 2 3 2 2 6 3

Results by method of assessment by Chin et al., 2015

Prognosis

- Lower quality of life

- Increased impairment in cognition and ADLs

- Entering care earlier

- Mortality

- Higher levels of distress in carers

Risk factors for depression in AD

- What do we know about risk?

First review in the literature

Inclusion criteria of studies

A. Depression in Alzheimer’s disease

B. Longitudinal prospective studies

C. Acceptable definition of depression in AD

Systematic review findings on risk factors

Risk factors (found to be significant)

Age*

Agitation/aggression*

Sleep disturbances*

Function*

Cognitive decline

Personal & family history

Stroke

Neuroticism

Measurement of outcome

NPI

RDC & DSM-IV

DSM-IV

HAM-D

CUSPAD

2/9 studies

5/9 studies

Who is at risk for depression in AD?

How is depression managed?

- Pharmacological management

Reviews provide

little/equivocal evidence- Bains et al., 2005

-Thompson et al., 2007 -Nelson et al., 2011-Sepehry et al., 2012

SSRI & non–SSRI

New review antidepressants in Alzheimer’s disease

- Antidepressants versus placebo for depressive symptoms

Tabet, Orgeta et al.

Psychological treatments

• Psychological interventions for depressive symptoms (Orgeta et al., 2015, BJP)

• Psychological intervention:

- WHO definition

- person with dementia is directly engaging in the intervention

- skills of managing/coping with depression/anxiety/distress

Results

• Depression: Standardised Mean Difference -0.22; 95% (CI) -0.41 to -0.03

• Strengths: TAU - enriched beyond usual care

Limitations: small RCTs, various models

A model for people with dementia

• Limited knowledge on best approaches for dementia

Evidence Based Interventions for depression for older people

Behavioral therapyCBTCognitive bibliotherapyProblem solving therapyBrief psychodynamic therapyLife review therapy

Person

vulnerabilities

Stressful life

events

Disease/Physical

health/Cognition

Activity

limitations

Negative/self-

critical thinking

DepressionLow rate of positive

emotion

Adapted by Fiske et al., 2009

What is behavioural activation? The theory

A behavioural psychotherapy approach based on:

Activity scheduling for obtaining positive reinforcement

Experiencing pleasurable events (i.e. rewards)

a) increasing experiences of pleasure

b) activating ‘approach behaviour’

c) engaging in behaviours that lead to experiences of mastery

d) meaningful behaviours consistent with life values

Systematic review of BA in older people

Included Studies

• 23 RCTs of BA in older people

• Settings – community vs care home vs inpatient settings

• Population/samples:

- depression diagnosis

- cognitive impairment (executive dysfunction, Alzheimer’s disease & cognitive impairment)

- chronic disease

• Intervention: BA only vs multicomponent BA (BA key part of intervention) vs BA-related

Behavioural activation in people with dementia

A total of 3 RCTs in AD (community settings)

Carers encourage pleasurable activities plus exercise plus other

components

Depression not a primary outcome/interventions did not meet BA model

Care home settings

IDEA: Intervention to prevent Depressive symptoms and promote well-being in EArly stage dementia

Aim 1: Develop a psychological intervention based on behavioural activation to prevent

depressive symptoms by

- Consultations with people living with dementia, their families & professionals

- Via individual interviews and focus groups

- MRC guidance for developing the ‘treatment’ manual

The IDEA study is funded by

Focus group consultation: Why being active is important for people living with dementia?

• Being active stimulates the mind:

“it stimulates the brain, it stimulates the body, and that’s important too”

• Being active gives structure to your week, improves self-esteem, gives you a purpose,

helps you in staying calm: “There should be at least one thing every day that is enjoyable,

because then there is a purpose in that day being there.”

• ‘Being active’ associated with loss, adapting to loss, feeling low and anxious

• Being active has gains: “can ward off depression and loneliness” , and “not being only at the

receiving end”

IDEA: Intervention to prevent Depressive symptoms and promote well-being in EArly stage dementia

Aim 2: Feasibility RCT

Key questions:

a. is the intervention acceptable and feasible?

b. is the study design feasible for a Randomised Controlled Trial?

Sample: 60 people with dementia and their family carers

Inclusion criteria:

- Mild dementia (MMSE ≥ 20)

- Diagnosis in the last 6 months

- Living in the community

- Available family carer

Exclusion criteria:

- Clinician’s assessment of suicide risk

Risk factors for

depression in AD

Natassa Steck

Dr Claudia Cooper

The IDEA study is funded by

Antidepressants review

AD

Dr Naji Tabet

Dr Ramin Nilforooshan

Professor Rob Howard

IDEA Project

Dr Rebecca Gould

Dr Rebecca Jones

Professor Gill Livingston

PPI

Tracey McDermott

Gillian Harrison

@IDEAProjectUCL

Longitudinal cohort study

risk factors for depression

in AD

Julia Beckwith

Professor Gill Livingston