dépression / apathie diagnostic / evaluation
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UE1.2.4
Spécificités des méthodes et outils d’évaluation
Dépression / Apathie Diagnostic / Evaluation
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PART1dADpatients-Whoarethey?dAD:DepressionofAlzheimer‘sDisease
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dADpatientsWhoarethey?
Depressioninoldage:generalconceptDepressionasoneneuropsychiatricsymptomofdementiaDiagnosisofdepressioninAD
PharmacologicaltreatmentofdepressioninAD
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Depressioninoldage:generalconcept
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TheClassicalDepressiveSymptomsaccordingtoDSM*
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*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
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Depressionintheelderly1
• Fullycharacterizedmajordepressionislesscommonthandepressive
symptoms,whichareasfrequentasinearlierlife
• Depressedmoodmaynotbethemajorcomplaint
• Somatic(e.g,pain)andcognitivecomplaintsmaydominate
• Anxiety,irritabilityandapathyaremorefrequentthaninearlierlife
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DepressionasoneneuropsychiatricsymptomofDementia
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DepressionasoneneuropsychiatricsymptomofDementia
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CognitiveSymptomsMemoryLanguageAttentionApraxia
Non-Cogni(veSymptomsApathy
DepressionAgita>on
Psycho>csymptoms
LossofAutonomyinActivitiesofDailyLivingIncreaseinCaregiverBurden
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DepressioninAD2
• Verycommon:Prevalenceof77%overa5-yearperiod*
• Oftenassociatedwithapathyandincreaseinirritability
• Noclearassociationbetweendementiaseverityanddepression
• Increasestheburdenofbothpatientsandcaregivers
• Isassociatedwithagreaterdeclineinqualityoflife**
• Earlierinstitutionalization**
• Increasedriskofmortality**
• Hasasignificanteconomicimpact*Steinbergetal.,2008;**LyketsosCGetal.,2002;Fernández-Martínezetal.,2008
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Prevalenceofneuropsychiatricsymptomsovera5-yearperiod
Five-year prevalence of NPI symptoms (NPI >0) in the Cache County Study (Steinberg et al., 2008).
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408patients:63%AD11%VaD6%mixed20%otherdementias>65yearsold
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SeverityofADandprevalenceofdepression2
N=499ADpatientsREAL.Frstudy,Benoit&al;RevMedInt,2003
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DepressioninAlzheimer’sDisease2
minimum3symptomspresentduringthesame2-weekperiod(oneiseitherdepressedmoodordecreasedpleasureinresponsetousualactivities)
Irritability
Sleepdisorders
FatigueLossofenergy
Dementia Depressed mood
Decreased pleasure in response
to usual activities Feelingof
worthlessness
Disruptioninappetite
SocialisolationWithdrawal
Psychomotorchanges
Thoughtsofdeath
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2 DepressioninAD≠depressioninelderly
dAD DepressioninelderlyHigherfrequencyofMotivationalDisturbancessuchas: fatigue
psychomotorslowing
apathy
HigherfrequencyofMoodSymptomssuchas: depressedmood
anxiety
suicidality
sleepand
appetitedisturbances
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DiagnosisofdepressioninADandoverlaps
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DiagnosisofdepressioninAD3
• Inclinicalpractice,diagnosisofdepressioninADincludes:• areviewofpatient‘smedicalhistory• aphysicalexamination• acognitiveexamination• abehaviouralexaminationincludingsuicidalideation• interviewswithfamilymembers(informants)*
• ProvisionalNIMHDiagnosticCriteriaforDepressionofADusedtodefinepatientswithADanddepression
• Ratingscalesappropriateformeasuringeffectsofastudydruginaclinicaltrialwithdementedpatients:NPIandCSDD
*www.alz.org/care/alzheimers-dementia-depression.asp;Tengetal.,2008
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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
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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.
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Teng et al., 2008
NIMH-dAD(Results)
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Difficultiesencounteredindailyclinicalpractice
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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
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!Lossofordiminishedmotivationincomparisontothepatient’spreviousleveloffunctioningandwhichisnotconsistentwithhisageorcultureforatleast4weeks
!Thesechangesinmotivationmaybereportedbythepatienthimselforbytheobservationsofothers
!Lossof,ordiminished(min2/3features)• goal-directedbehaviour• goal-directedcognitiveactivity• interest• emotion
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DepressioninAD–Apathy
Apathy:motivationaldisturbanceDepression:emotionaldisturbance
Diminishedmotivation(alsotodothingsusuallyfoundenjoyable)BluntedEmotion
DepressedMoodInabilitytoexperiencepleasurefromactivitiesusuallyfoundenjoyable(Anhedonia)
FatigueWithdrawal
LossofinterestCognitiveworseningIrritability
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Benoitetal.,2012:N=734;Age=80±6.6years;M/F=38/62%;MMSE=23.1±2.2
DepressionD
iagnosis
ApathyDiagnosis
3 DepressioninAD–Apathy
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TreatmentofdepressioninAD
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!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
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!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
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Conclusions
Depressionisanemotionaldisturbanceandhighlydisablinginoldage.DepressioninADjeopardizesADLandpromotesinstitutionalization.Apathyisamotivationaldisturbanceoftenencounteredindementiaandmaybemistakenasdepressivesymptom.DepressioninADisdifficulttomanageasthereislackofeffectivepharmacologicaltherapy.Itisnecessarytosearchforanewtreatmentstrategy.
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PART2AssessmentofdepressivesymptomsindADpatients
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AssessmentofdepressivesymptomsindADpatients
Differenttypesofassessment(GDS,NPI,CSDD…)NeuropsychiatricInventory(NPI)CornellScaleforDepressioninDementia(CSDD)
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Differenttypesofassessment
Thepointofviewof
TheClinician+-
MADRSCSDD
ThePatient+-GDS
TheCaregiver+-NPI
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§ 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
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NPI–Dysphoriadomain(1/2)
Does(S)seemsadordepressed?Does(S)saythathe/shefeelssadordepressed?(P)Yes:£No:£Responsesshouldbebasedonthepast4weeks.CaregiverInterview*Frequency0-4Severity0-3 31
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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:£
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CornellScaleforDepressioninDementia(CSDD)(1/2)MoodRelatedSignsAnxietySadnessLackofreactivitytopleasantevents:IrritabilityBehavioraldisturbancesAgitationRetardationMultiplephysicalcomplaints:Lossofinterest
IdeationalDisturbanceSuicideSelf-depreciationPessimismMood-CongruentDelusionsPhysicalSignsAppetiteLossWeightLossLackofenergyCyclicFunctionsDiurnalvariationofmoodDifficultyfallingAsleepMultipleawakeningsduringsleepEarlyMorningawakenings
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Theclinicianratingisbasedonallavailableinformationcomingfromthepatient,caregiverinterviewandanyadditionalmaterials(e.g.,chartnotes)
§ SCORINGSYSTEMü 0=absentü 1=mildtointermittentü 2=severeü 9999=unabletoevaluate
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CornellScaleforDepressioninDementia(CSDD)(2/2)
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