Depression, cognitive impairment, and disability often coexist in older adults. Therefore, to effectively treat late-life depression, clinicians need to evaluate the presence and degree of the patient’s cognitive deficits and level of disability.
This article highlights the importance of psychosocial interventions in the treatment of depressed, cogni-tively impaired, and disabled older adults; describes existing psychosocial interventions for this population; and presents a case illustration of problem adaptation therapy (PATH). PATH is a novel home-delivered intervention that aims to reduce both depression and disability in depressed older adults with significant cognitive impairment (including mild to moderate dementia) and disability.1,2
Assessment of depression. The clinician must conduct a thorough evaluation that includes a review of the current depressive symptoms, past history of depression, history of pharmacological and psychosocial treatments and their effectiveness, and an evaluation of suicidal ideation. For most cognitively impaired elders, the clinician needs to interview the caregiver and obtain information that may not be available with the patient self-report. Instruments that have been validated in the assessment of depression in cognitively impaired elders may help in the evaluation (Table 1).
Because depressed elderly patients often do not report depressed mood but do report lack of interest or pleasure in activities, the clinician needs to use the patient’s language and experience in making an evaluation. Sometimes depressed older adults use words other than “depression,” such as feeling blue, down, discouraged, and not motivated. Because geriatric depression may be comorbid with other illnesses, symptoms that are caused by depression must be differentiated from those of another illness. Sometimes this differentiation is extremely difficult, because depression may exacerbate existing physical symptoms.
Assessment of cognitive impairment. An important aspect of the evaluation is the assessment of cognitive impairment. The clinician may ask the patient and the caregiver about the effects of cognitive difficulties on the patient’s functioning and identify cognitive strengths as well as deficits. Specific questions about the patient’s ability to start and stay with a new task until it is completed, to sustain attention and concentrate while reading or speaking with others, and to remember recent events and conversations may provide important infor-mation about the patient’s everyday functioning.
Screening tools such as the Mini-Mental State Examination (MMSE) may help identify overall cognitive impairment, but they are generally not sensitive to executive deficits or mild cognitive impairment.3 A somewhat more inclusive measure is the Modified Mini-Mental State Examination—the extended version of the well-known MMSE.4 Another screening instrument that has shown increased sensitivity to milder forms of cognitive compromise is the Montreal Cognitive Assessment (MoCA).5 (The complete MoCA test, as well as normative data and instructions for use, is available online at http://www.mocatest.org.) Translations into multiple languages are also available. These cognitive screening instruments can be administered with minimal training.
? Despite the effectiveness of pharmacological treatments in the acute phase of late-life depression, symptom remission is achieved in fewer than 40% of elderly depressed patients with cognitive impairment, with or without dementia. Therefore, effective psychosocial interventions for this population are needed. However, most psychosocial interventions for the acute treatment of geriatric major depression are designed for “young-old,” cognitively intact, ambulatory patients who can follow outpatient treatment plans.
? To treat depressed older patients with comorbid cognitive impairment and disability, psychosocial interventions need to be modified to include involvement of a caregiver, home delivery of the interventions, and environmental changes to help improve everyday functioning. With these modifications, psychosocial interventions may provide relief to a large group of elderly patients with depression who may not respond to antidepressant medication treatment.
Instruments that are administered in the context of a formal neuropsychological evaluation can provide a more accurate evaluation of cognitive deficits; ie, a score of 130 on the Mattis Dementia Rating Scale has a 98% sensitivity and 97% specificity for the diagnosis of Alzheimer dementia.6,7 Neurocognitive assessment conducted by a neuropsychologist provides assessment of the patient’s cognitive strengths and weaknesses that is interpreted in the context of the patient’s premorbid functioning, age, ethnicity, and education, and can yield essential knowledge that contributes to treatment success.
Assessment of functioning. In addition to the assessment of depression and cognitive impairment, the clinician needs to evaluate the patient’s functional, behavioral, and physical limitations (eg, hearing, visual, mobility problems). Information must be collected from both the patient and the caregiver; careful questioning may identify and evaluate discrepancies in their reports. The clinician evaluates how depression, cognitive impairment, and disability have affected the patient’s everyday functioning (ie, what activities the patient can no longer do; what the patient’s past and current pleasurable activities are; what effects, if any, the patient’s cognitive difficulties may have had on taking medication and performing activities of daily living). Available clinician-administered instruments may be helpful in providing information on the patient’s functioning (Table 1).
Despite the effectiveness of pharmacological treatments in the acute phase of late-life depression, symptom remission is achieved in fewer than 40% of elderly depressed patients with cognitive impairment, with or without dementia.8-11 Therefore, effective psychosocial interventions for this population are needed. Despite this need, most psychosocial interventions for the acute treatment of geriatric major depression are designed for “young-old” (average age, 65 to 70 years), cognitively intact, ambulatory patients who can follow outpatient treatment plans.12 To effectively treat depressed older patients with comorbid cognitive impairment and disability, these psychosocial interventions need to be modified (eg, involvement of a caregiver; home delivery of the psychosocial intervention; environmental changes to help depressed, cognitively impaired older adults improve their everyday functioning). The following interventions have been designed for depressed older patients with varying degrees of cognitive impairment.
Problem-solving therapy for mild executive dysfunction (PST-ED). PST-ED is a 12-week outpatient treatment for ambulatory depressed elders with mild executive dysfunction. It consists of 7 problem-solving stages and helps the patient identify his or her problems and find the best possible solution by learning the problem-solving stages and applying them to future problems. PST-ED has been found to be effective in reducing depression and disability in this population.13,14
Interpersonal psychotherapy for mild cognitive impairment (IPT-CI). IPT-CI has been modified for depressed elderly patients with mild cognitive impairment. Modifications include the systematic incorporation of concerned caregivers into the treatment process; joint patient-caregiver sessions help promote better understanding, communication, and respect.15,16 Finally, the IPT-IC therapist helps the dyad (patient and caregiver) adjust to their role transition as a result of the patient’s cognitive deficits and impaired functioning.
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