2004 overview: Key Learning Messages in Old Age Psychiatry
In this overview Dr Jeremy Seymour, England, discusses some of the issues in Old Age Psychiatry that attracted special interest in 2004.
2004 has seen a steady accumulation of significant research findings in the field of old age psychiatry. The "organic" areas I have chosen to focus on are mild cognitive impairment; the disclosure of a diagnosis of dementia; cognitive enhancers; carer strain; and the management of behavioural and psychological symptoms (BPSD) in dementia.
The separation between "functional" and "organic" is becoming extremely tenuous, for example with the delineation of vascular depression. The "functional" area I have chosen to focus is depression in residential homes.
Mild Cognitive Impairment
With older people becoming more aware of treatments for dementia, many more are presenting with mild cognitive deficits, usually a subjective complaint of poor memory, when a diagnosis of dementia is not justified. It is still not clear in the literature, which of these patients will go on to develop a dementia syndrome, diagnosable by standardised criteria.
In clinical practice, it is ideal to offer patients with so called "mild cognitive impairment" repeat cognitive testing annually, and to address optimally any cardiovascular risk factors such as hypertension or hypercholesteraemia.
A review article on the current status of mild cognitive impairment was published in February 2004, for those interested (ref. 1).
Sharing The Diagnosis Of Dementia
With the increasing international importance of users' movements, the issue of sharing the diagnosis of dementia has gained importance. Many people with dementia in its early stages deny there is a problem, either because they lack insight due to organic factors, or because they fear the consequences and implications of the diagnosis.
It is therefore particularly important that health staff in both primary and secondary care manage the whole process of making and sharing the diagnosis sensitively. If done well, users and carers will trust health professionals that effective interventions - both pharmacological and psychosocial - will help.
A systematic review published in February 2004 (ref. 2) suggested diagnostic disclosure in dementia is both inconsistent and limited, with the perspectives of people with dementia being largely neglected.
Evidence continues to accumulate of the efficacy of the acetylcholinesterase inhibitors, donepezil, galantamine and rivastigmine, in Alzheimer's Disease, mixed Alzheimer's and vascular dementia, and Lewi Body Dementia. Early diagnosis and intervention is increasingly important. The boundary between vascular dementia and Alzheimer's is blurred, and a diagnosis of a mixed dementia is justified in many cases.
A trial of a cognitive enhancer is therefore justified in the majority of cases attending a Memory Clinic, and it is becoming increasingly clear that "a trial" should be for at least 6 months.
Efficacy is now established in the domains of cognition, function, and behaviour. Effects of behaviour (described as behavioural and psychological symptoms of dementia - BPSD - by the International Psychogeriatric Association) are particularly important for carers (ref. 3).
Longer term outcome studies suggest cognitive improvements are sustained for up to 2 years following initiation of an acetylcholinesterase inhibitor. If the dementia is progressing, dosage increase, switching to another acetylcholinesterase inhibitor, or the addition of memantine are possible therapeutic manoeuvres, accompanied by psychosocial interventions.
Further evidence of efficacy of acetylcholinesterase inhibitors in BPSD, delirium, Lewi Body Dementia and moderate-severe dementia (ref. 4) has also accumulated (ref. 5).
Flying in the face of this accumulating evidence published worldwide in peer-reviewed journals is the AD 2000 study , published in the Lancet June 26th 2004.
Many commentators have concluded that this trial is severely methodologically flawed because of the repeated drug-free washout periods in the longer term phase of the trial.
Evidence of the efficacy, safety and economic benefit of memantine in moderate to severe dementia has steadily accumulated since 1999. A randomised controlled trial of 404 patients published in JAMA in 2004 strongly supported the combination therapy of memantine added into donepezil in patients already taking donepezil (ref. 6).
Carer strain is partly subjective, but is also related to the degree of BPSD in the demented, cared-for person. However, is BPSD partly generated itself by particular caregiving styles?
de Vugt et al. (ref. 7) from Maastricht have suggested that carers who develop non-adaptive strategies in their caring role engendered more disinhibition, irritability, agitation and wandering in the people they were caring for.
Further, carers with such non-adaptive strategies did badly in terms of their own well-being and sense of competence.
This has significance for psycho-educational approaches to carers: if carers can learn and adopt more adaptive strategies, BPSD may be reduced and the caring relationship improved.
Up to 90 % of Alzheimer's patients experience symptoms such as hallucinations, delusions, agitation, affective disturbance or apathy at some point in their illness. These symptoms are surprisingly prevalent in the early stages of the illness - and often precipitate referral and diagnosis - ie., are not confined to later stages.
BPSD are particularly distressing for family caregivers, and it is often these symptoms, rather than the severity of cognitive decline, that precipitates admission to hospital and/or admission to institutional care.
A range of pharmacological strategies have developed over the last decade, though good quality randomised controlled trials (RCTs) in this difficult-to-study group of patients are rare. Holmes et al. (ref. 8) published an RCT in July 2004 suggesting that donepezil has efficacy in BPSD in patients with mild to moderate Alzheimer's.
Acetylcholinesterase inhibitors such as donepezil are well-tolerated, and have a better side-effect profile than other drugs used in BPSD such as haloperidol, trazodone or carbamazepine.
Depression In Residential Homes
Up to 20 % of older people live in residential or nursing homes towards the end of their lives, in most westernised countries. Entry into such institutions is often due to a combination of medical, social, and psychological factors.
The prevalence of depression in this population is high, though there is an extensive literature to suggest that depression is underdiagnosed and undertreated, and that neither primary or secondary care services are well co-ordinated to treat this common condition (ref. 9).
Eisses et al. (ref. 10) studied 479 residents of residential homes in Holland and found that factors most associated with depression were loneliness, neuroticism, and functional impairment. Factors not associated with depression were age, gender, recent life events, recent hospital admission, and perhaps most surprisingly, chronic physical illness.
Untreated depression increases mortality up to a factor of two-fold in older people, for both cardiac and non-cardiac causes. Serotonin specific re-uptake inhibitors (SSRIs) are safe and effective in older people with depression and co-morbid cardiac disease (ref. 11; ref. 12; ref. 13).
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11. Davies SJC, Jackson PR, Potokar J and Nutt DJ. Treatment of anxiety and depressive disorders in patients with cardiovascular disease. British Medical Journal 2004; 328 (7445); 939-943. (Note: Free full text article)
12. Sheikh JI, Cassidy EL and Doraiswamy PM. Efficacy, safety and tolerability of sertraline in patients with late-life depression. Journal of the American Geriatric Society 2004; 52 (1); 86-92.
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Published on CNSforum 31 Dec 2004