Depressive disorder in alzheimer's disease patients. Different aspects in the early and late stages

Arch. Gerontol. 0167-4943/98/$19.00

Geriatr. suppl. 6 (1998) 343-346 0 1998 Elsevier Science Ireland

DEPRESSIVE

DISORDER

DIFFERENT

ASPECTS

P.

A.

MONINI,

Geriatric I-00144

IN IN

ALZHEIMER’S

THE

TOCNETTI,

Department, Rome, Italy

S.

DISEASE

EARLY

C.

AND

SERGIO

Eugenio

Ltd. All right

Hospital,

PATIENTS.

LATE

STAGES

L.

BARTORELLI

and

343

reserved

Piazzale

Umanesimo,

10.

SUMMARY Depression associated with dementia is a significant problem. It can result in worsening of cognition, more caregiver stress and, at least, early institutionalization of the patient. However, depression in persons with dementia has received limited interest despite the fact that it is a potentially treatable condition. In this paper the relationship between depression and functional abilities in 90 Alzheimer’s disease (AD) patients was investigated. The frequency of depression mean values of basic and instrumental activities of daily living was 30 %. The were significantly (p < 0.01) more impaired in depressed mild-moderately demented patients in comparison with non depressed ones, while no differences were observed in severely demented patients. These data are suggestive for the capability of treating depression and improving functional status in dementia. Keywords:

dementia,

depression,

activities

of daily

living

INTRODUCTION Depression Reifler

,

1992;

Migliorelli

may

not

and

dysfunction

the

relationship

implications task.

port

on

memory

The tion.

et

on

for

between

depression

and

mood.

To

the

as

investigate in a selected

well the

of fact is

as

that

sample

the

treated. between

of Alzheimer’s

PATIENTS AND METHODS For this study, eligible service of S. Eugenio Hospital type based on NINCDS-ADRDA

more

depressive

depression

depression, (AD)

it

distress However,

is

not

yet

ability,

on

is

is

not

a sim-

patient’s

re-

of cognition

diagnosis

is

a field

investiga-

depression

is

poorly

the

study

a potentially

current and

of not

judgement. of

have that

Because

caregiver’s

also

fully

behavioral

the

the

the

patients evidence he purpose

disease

on

that

significant

symptoms.

patients,

often

depression

individuals

is based

and

Wagner,

caregivers. and

these

demented

with

inadequately

of

demented

consistent

relationship

severity

and

many

in

(Teri

and

of

functional

of depression

but

dementia

complex

impairment,

severely

information,

severity

is

and

AD

Teri

cause

patients

AD

of

1989;

symptoms

depression

and in

the

and

cognitive

duration

Jeste,

nevertheless, to

diagnosis

especially

disorder

but 1989)

recognize

the

patient’s

Moreover,

associated

on

complication

and

experience

diagnosis,

work

a potential

Wragg

Patients

et al.,

they

of

as

1989;

(Pearson

how

the

al., 1995).

presence,

impact

cognized

al.,

Traditionally, the

identified

et

criteria

problems,

based

been

Rovner

meet

understood

ple

has

1987;

treatable

functional

rewas ability

patients.

patients were those who were seen in with a primary diagnosis of dementia (McKhann et al., 1984) criteria.

our outpatient of Alzheimer Semistructural

to

344

interviews were administered to the patients and their caregivers by a neuropsychologist or a geriatrician who had received extensive training and supervision with the research measures and interview. As well, DSM IV (APA, 1994) criteria for depressive disorder were used to divide AD patients in two groups: depressed and non-depressed. Subjects were given a comprehensive geriatric evaluation which included thorough neurological and physical examinations, laboratory tests and complete blood chemistry, neuropsychological and psychosocial assessments. The neuropsychological assessment consisted of a battery of tests (evaluating short and long term memory, spatial memory, attention and discrimination, calculation ability, praxis), but in the present study for statistical analysis we considered only the mini mental state examination (MMSE) scores (Folstein et al., 1975). The patients were evaluated about the dementia stage according to global deterioration scale (Gds) (Reisberg et al., 1982). The geriatric depression scale (CDS) (Brink et al., 1982) was used in patients with a Cds ranging from 1 to 4. Patients with dementia in late stages (Cds 5-7) had only a structured interview. The principal caregiver of each patient had a structured interview with the psychologist. The patient’s functional ability was assessed using the activity of daily living (ADL) (Katz et al., 1963) and the instrumental activity of daily living (IADL) (Lawton and Brody, 1969) scales. All available information, including the patient and caregiver interviews and medical charts were discussed with the treating staff and were used to complete data bases. Final diagnoses were assigned by consensus of investigators. To provide an objective and valid measure of overall medical burden, the medical investigator completed the cumulative illness rating scale (CIRS) (Parmelee et al., 1995) after reviewing the medical history of the subjects, performed the physical examination at the time of enrollment and all available laboratory tests. RESULTS Descriptive pressed

subjects

mean sed

information

age and

are

in no

scores

AD

in patients

differences

dementia

It

depressed

non-depressed

in

Tables found

but

high:

also

II.

had is

depression

not

the

significantly the

the

in

that

when

AFFECTIVE,

COGNITIVE AND DEMENTED PATIENTS

Depressed Sample size Age (years) GDS ADL IADL MMSE t -

73 17 14 5 16 Student

t

test;

17 + 7 T 7 T

FUNCTIONAL (Cds l-4)

There

and abilities

impairment

than

is

severe.

more

Non-depressed

8.5 3.8 5.4 2.2 5.4 p

74 5 10 7 20 -

probability;

35 + 7 + 7 T

t

7.1 6.5 4.8 2.0 6.6 NS

0.446 7.029 2.706 3.274 0.542 -

not

significant

severe of

PARAMETERS -+ SD)

(mean

De-

sample.

mild-moderate

dementia

of (depres-

patients.

whole

functional

greater

case

groups

dementia

% in

non-de-

differences

patient

severe

30

and

significant

two

and

found a

No the

about of

been

this

and

depressed

I

VALUES OF MILD-MODERATELY

Notes:

I

between

frequency

has

concerning

mild-moderate

quite

the

measures

were

patients

ones,

all

both

is in

patients.

moderately

Table

shown

MMSE

non-depressed)

pression were

and

for

IN

P<

NS 0.0001 0.01 0.01 NS

mildin

the

345 Table

II

VALUES

OF

SEVERLY

AFFECTIVE,

COGNITIVE

DEMENTED

AND

PATIENTS

(Gds

Depressed Sample size Age (years) ADL IADL MMSE Notes:

t -

Student

t

(mean

PARAMETERS

+

6.5 3.4 2.1 6.1

test;

p -

probability;

are

common

t

25 + + T ?-

76 16 2 8

IN

SD)

Non-depressed

13 + 7 T T

75 16 2 7

FUNCTIONAL

5-7)

8.2 2.7 1.9 4.3

P<

0.381 0.991 0 0.588

NS

-

not

NS NS NS NS

significant

DISCUSSION Depressive

symptoms

frequency

in

tional

ability

when

the

true

in

the

different

by

decreasing

patients the

very

be

in to

tially

treatable

condition

not.

Moreover, ability.

pressions”

because levels

social

ones.

creasing by

of

there

Thus

standard

psychiatric

ness,

other

creased

affective

subjectively servers

may Despite

liable

what

our

knowledge

procedures

tidepressant

appears

that

but

treat

depression

work

concerns

we

about

promoted

the

non the

psychological

responsible

for

deat

any

the

in-

to

experienced

the

doctors.

Thus

among

sad-

observations

even in

clinically, response.

pharmacological

caregiver. their

“several

in

of

the

demented

absence

deof

patients,

ob-

mood”.

treatment

also

is and

and

and

is

cognition

distinguish

Thus

neurotransmission,

track

and

not

happens

“depressed

depression

support patients

be

it

a poten-

subjectively

mood

intensity.

is

are

by

the It

potentially

and

low

but

factors.

while

there

those

more

communication

be

do

as

as to

subtype or

and

by

mood

or

drugs

mechanisms,

caregiver

depressed

range

medication,

dications

the

is cognitive

depression

neurobiological

observed by

the deficit

behavior,

might

occur

this

of

biological

patients

from

“depression”,

note

the

and

patient’s

by

on

experienced

reactivity, experienced

modifiable

func-

may

onset

to

equal

reduce

depression

because

pathogenic

symptoms

subjectively

also

pathogenesis

of

of

with

may

the

related

demented

several

observed ratings

forms

in

organization,

between

AD

effects

that

in

be

be

bad

are

those

patient,

in

occurs

capability at

awareness may

it

or

functional

should

differences

disparity the

it

suggest

conceptual

initiative,

better

stages

has

and Depression

Depression

depression and

We

and

the

late

recognize

patients

disease.

disease. to

the

AD

the

decreased

the

depression

functional

all

of related

depression

important

or

their

stage

could of

in

of

motivation

recognize

early

impairment onset

stages

caregivers;

In

mild the

there

are

guide

to

We

used

currently the

choice

anme-

methods

(Miller, the

psychological

the

caregivers

for

re-

of

psychotropic

dementia goal

no

1989)

to

is

346 to

help

them

to

acquire

patient’s

transformation

moderate

stage,

managing

the

is

stress

trials functional

In

with

function

and are

and

it

inevitable.

dealing

useful

of

the

depression about of

to

care

these

of

on

the

changes

support and

the

the

stage loss.

using the

knowledge tolerate

to

severe

grief

needed status

is

the

the

a sufficient

the

larger

acceptance

to

their in

that

psychological number

of

disease, in

caregiver

Additionally,

efficacy

the

the

the

support

of

patients,

sense

worsening is

investigations

antidepressant

of

the

better disease

necessary also

in

the In

of

about and

drugs

recognize

life-style.

for

cognition, controlled

improving

the

patients.

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