Dementia: Quality of Care

1. Preventing depression & promoting well-being in early
stage dementia
Senior Fellow of the Alzheimer's Society, & Senior Research Associate, UCL
Dr Vasiliki Orgeta

2. 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%

3. 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

4. Prognosis
- Lower quality of life
- Increased impairment in cognition and ADLs
- Entering care earlier
- Mortality
- Higher levels of distress in carers

5. 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

6. 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

7. Who is at risk for depression in AD?

8. 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

9. New review antidepressants in Alzheimer’s disease
- Antidepressants versus placebo for depressive symptoms
Tabet, Orgeta et al.

10. 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

11. A model for people with dementia
• Limited knowledge on best approaches for dementia
Evidence Based Interventions
for depression for older
people
Behavioral therapy
CBT
Cognitive bibliotherapy
Problem solving therapy
Brief psychodynamic therapy
Life review therapy
Person
vulnerabilities
Stressful life
events
Disease/Physical
health/Cognition
Activity
limitations
Negative/self-
critical thinking
Depression
Low rate of positive
emotion
Adapted by Fiske et al., 2009

12. 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

13. 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

14. 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

15. 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

16. 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”

17. 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

18. 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