Carlos Augusto de Mendonça Lima

Systematic review of the effectiveness of non-pharmacological interventions to improve quality of life of people with dementia

BACKGROUND People with dementia report lower quality of life, but we know little about what interventions might improve it. METHODS We systematically reviewed 20 randomized controlled trials reporting the effectiveness of non-pharmacological interventions in improving quality of life or well-being of people with dementia meeting predetermined criteria. We rated study validity with a checklist. We contacted authors for additional data. We calculated standardized mean differences (SMD) and, for studies reporting similar interventions, pooled standardized effect sizes (SES). RESULTS Pooled analyses found that family carer coping strategy-based interventions (four studies, which did not individually achieve significance; n = 420; SES 0.24 (range 0.03-0.45)) and combined patient activity and family carer coping interventions (two studies, not individually significant; n = 191; SES 0.84 (range 0.54-1.14)) might improve quality of life. In one high-quality study, a care management system improved quality of life of people with dementia living at home. Group Cognitive Stimulation Therapy (GCST) improved quality of life of people with dementia in care homes. CONCLUSION Preliminary evidence indicated that coping strategy-based family carer therapy with or without a patient activity intervention improved quality of life of people with dementia living at home. GCST was the only effective intervention in a higher quality trial for those in care homes, but we did not find such evidence in the community. Few studies explored whether effects continued after the intervention stopped. Future research should explore the longer-term impact of interventions on, and devise strategies to increase, life quality of people with dementia living in care homes or at home without a family carer.

A randomised, double‐blind comparison of the efficacy and safety of citalopram compared to mianserin in elderly, depressed patients with or without mild to moderate dementia

Depression is the most common psychiatric disorder among the elderly and in old age may interact with emotional and cognitive functioning. Depression in old age has been shown to be associated with degenerative changes in the brain. It is, therefore, important that in this patient population antidepressants with a favourable tolerability profile, such as the selective serotonin reuptake inhibitors (SSRIs), are examined for both antidepressant efficacy and effect on cognitive function and emotional impairment. This randomised, double‐blind study compared the efficacy and tolerability of citalopram and mianserin in 336 elderly, depressed patients with or without dementia. Patients received either citalopram 20–40 mg/day or mianserin 30–60 mg/day for 12 weeks. The treatments were equivalent with respect to change in Montgomery–Åsberg Depression Rating Scale (MADRS) total score; patients in both treatment groups responded well. Patients with dementia showed a smaller decrease in total MADRS score than patients without dementia. Both treatments were well tolerated with a relatively low incidence of adverse events. Fatigue and somnolence were more frequent with mianserin, while insomnia was more frequent with citalopram. Overall, this study showed that the two treatments were equivalent in efficacy, and that citalopram is an effective, well‐tolerated and non‐sedative treatment for elderly depressed patients with or without dementia. Copyright

A systematic review of treatments for refractory depression in older people

OBJECTIVE The authors systematically reviewed the management of treatment-refractory depression in older people (defined as age 55 or older). METHOD The authors conducted an electronic database search and reviewed the 14 articles that fit predetermined criteria. Refractory depression was defined as failure to respond to at least one course of treatment for depression during the current illness episode. The authors rated the validity of studies using a standard checklist and calculated the pooled proportion of response to any treatment reported by at least three studies. RESULTS All the studies that met inclusion criteria investigated pharmacological treatment. Most were open-label studies, and the authors found no double-blind randomized placebo-controlled trials. The overall response rate for all active treatments investigated was 52% (95% CI=42-62; N=381). Only lithium augmentation was assessed in more than two trials, and the response rate was 42% (95% CI=21-65; N=57). Only two studies included comparison groups receiving no additional treatment, and none of the participants in these groups responded. In single randomized studies, extended-release venlafaxine was more efficacious than paroxetine, lithium augmentation more than phenelzine, and selegiline more than placebo. CONCLUSIONS Half of the participants responded to pharmacological treatments, indicating the importance of managing treatment-refractory depression actively in older people. The only treatment for which there was replicated evidence was lithium augmentation. Double-blind randomized controlled trials for management of treatment-refractory depression in older people, encompassing pharmacological and nonpharmacological therapies and populations that reflect the levels of physical and cognitive impairment present in the general older population with depression, are needed.

Are personality disorders more frequent in early onset geriatric depression

This preliminary study evaluates the prevalence of personality disorders (PD) in a sample of 37 elderly recovered depressed and non-demented patients, using the French version of the Vragenlijst voor Kenmezken van de Persoonlijkheid (VKP) or Questionnaire on Personality Traits (QPT). The prevalence of definite personality disorder was 65% with predominance of Cluster C and particularly dependent and avoidant PD. The rate of PDs was higher in early onset (73%) than in late onset (45%) geriatric depression, even though there is only a trend towards statistical significance (Chi square = 2.588, p = 0.107). These results are consistent with those of previous reports using different PD assessment methods, supporting evidence that the QPT could be useful in PD assessment of elderly French speaking patients.

Suicidal behaviour in frontotemporal dementia patients—a retrospective study

Neurology Department, Hospital de Braga, Braga, PortugalAdditionally, the authors would like to add an Acknowledgement section:AcknowledgementOur thanks to Dr. Joaquim Duarte, Professor Carlos Lima, Professor Nuno Sousa and Professor IoannisSotiropoulos for their advice.The authors would like to apologize for these errors and any confusion it may have been caused.

Rapid-Cycling Affective Disorder in the Elderly: Clinical Subtype or Specific Course of Manic-Depressive Illness?

Rapid cycling is a relatively unusual presentation of bipolar affective disorder in the elderly. Four cases or rapid-cycling affective disorder (RCAD) in elderly women (aged 78-86 yr) are presented. Two patients began their bipolar illness in adulthood (aged 30 and 49 yr), and rapid cycles appeared secondarily in their elderly years (82 and 76 yr). The other two began their illness immediately with rapid cycles respectively at the age of 62 and 66. Added to the nine cases of RCAD in the elderly previously reported in the literature, a meta-analysis conducted on this small sample suggests that immediate entry in rapid cycles seems more likely to be associated with a late occurrence of bipolar illness (after 60 years of age) (P = .0035, Fishers Exact Test, two-tailed), and that very short cycles (< 2 weeks each) are more likely to be associated with female gender (P = .0047, Fishers Exact Test, two-tailed). Despite the small size of the sample, these results give some arguments to the hypothesis that RCAD is not a homogeneous syndrome but could be considered as a pattern of evolution, as well as clinical subtype, of the bipolar illness.

Declaração de consenso da seção de psiquiatria geriátrica da Associação Mundial de Psiquiatria sobre ética e capacidade em pessoas idosas com doença mental

CONTEXTO: A Secao de Psiquiatria Geriatrica da Associacao Mundial de Psiquiatria (AMP), desde 1997, vem desenvolvendo Declaracoes de Consenso relevantespara a pratica da Psiquiatria Geriatrica. Desde 2006, a Secao vem trabalhando para desenvolver uma Declaracao de Consenso sobre Etica e Capacidade em pessoas idosas com transtornos mentais. METODO: Uma Conferencia de Consenso foi realizada em Praga em setembro de 2008. Organizada pela Secao de Psiquiatria da Pessoa Idosa da AMP, ela contou com a participacao do International Council of Nurses, Alzheimer Europe e Alzheimer Disease International. Os participantes foram reconhecidos pela sua pericia nesse dominio e vieram de 11 paises. Incluiam psiquiatras, uma neurologista, um enfermeiro e representantes de cuidadores familiares. RESULTADOS: Apos dois dias de reunioes e debate, redigiu-se um rascunho da declaracao que foi submetida para analise nas diversas organizacoes/associacoes que participaram da reuniao. Apos as sugestoes finais recolhidas, um texto definitivo foi preparado em ingles e publicado. A presente versao em portugues e da responsabilidade de dois participantes lusofonos da reuniao, que sao tambem coautores da declaracao de consenso final. CONCLUSOES: Essa Declaracao de Consenso oferece aos clinicos em saude mental que cuidam de pessoas idosas com transtornos mentais, cuidadores, outros profissionais da saude e o publico em geral as definicoes e o debate sobre os principios eticos que podem frequentemente ser complexos e desafiadores, apoiados em orientacoes praticas para satisfazer tais necessidades e padroes eticos e encorajar a boa pratica clinica.

Versorgung suizidaler Älterer in der Schweiz

Zusammenfassung: Obwohl die Lebensbedingungen fur altere Menschen in der Schweiz eher gunstig zu sein scheinen, verhindern sie nicht hohe Suizidraten dieser Altersgruppe. Seit 1986 wird ein Anstieg im Verhaltnis von Suizidraten Alterer im Vergleich mit Jungeren verzeichnet. Angesichts des zunehmenden Anteils Alterer an der Gesamtbevolkerung wird mit einer Verdoppelung der Suizide Alterer bis 2030 gerechnet. Deshalb sind alten Menschen angepasste Masnahmen zur Suizidpravention dringend erforderlich.