Manuel Gonçalves-Pereira

Affective disorders and risk of developing dementia: systematic review

BACKGROUND Affective disorders are associated with cognitive disturbances but their role as risk factors for dementia is still not fully investigated. AIMS To evaluate the risk of developing dementia in individuals with a history of affective disorder. METHOD We conducted a systematic review of case-control and cohort studies addressing the risk of developing dementia in people with affective disorders. To the best of our knowledge, this is the first systematic review that has included studies evaluating this risk specifically in people with bipolar disorder. RESULTS Fifty-one studies were included. Most of the studies found an increased risk for developing dementia in individuals with depression. Greater frequency and severity of depressive episodes seem to increase this risk. The evidence is contradictory regarding whether there is a difference in risk in people with early- or late-onset depression. The few available risk estimates for dementia in people with bipolar disorder suggest an even higher risk than for those with depression. CONCLUSIONS Affective disorders appear to be associated with an increased risk of developing dementia, and one that is dependent on clinical and demographic variables. Depression may be both a prodrome and a risk factor for dementia. Future research should aim to elucidate the mechanisms that mediate these links.

Development and Validation of an International Risk Prediction Algorithm for Episodes of Major Depression in General Practice Attendees The PredictD Study

CONTEXT Strategies for prevention of depression are hindered by lack of evidence about the combined predictive effect of known risk factors. OBJECTIVES To develop a risk algorithm for onset of major depression. DESIGN Cohort of adult general practice attendees followed up at 6 and 12 months. We measured 39 known risk factors to construct a risk model for onset of major depression using stepwise logistic regression. We corrected the model for overfitting and tested it in an external population. SETTING General practices in 6 European countries and in Chile. PARTICIPANTS In Europe and Chile, 10 045 attendees were recruited April 2003 to February 2005. The algorithm was developed in 5216 European attendees who were not depressed at recruitment and had follow-up data on depression status. It was tested in 1732 patients in Chile who were not depressed at recruitment. Main Outcome Measure DSM-IV major depression. RESULTS Sixty-six percent of people approached participated, of whom 89.5% participated again at 6 months and 85.9%, at 12 months. Nine of the 10 factors in the risk algorithm were age, sex, educational level achieved, results of lifetime screen for depression, family history of psychological difficulties, physical health and mental health subscale scores on the Short Form 12, unsupported difficulties in paid or unpaid work, and experiences of discrimination. Country was the tenth factor. The algorithms average C index across countries was 0.790 (95% confidence interval [CI], 0.767-0.813). Effect size for difference in predicted log odds of depression between European attendees who became depressed and those who did not was 1.28 (95% CI, 1.17-1.40). Application of the algorithm in Chilean attendees resulted in a C index of 0.710 (95% CI, 0.670-0.749). CONCLUSION This first risk algorithm for onset of major depression functions as well as similar risk algorithms for cardiovascular events and may be useful in prevention of depression.

Quality of life in patients with cognitive impairment: validation of the Quality of Life-Alzheimer's Disease scale in Portugal.

BACKGROUND Quality of Life-Alzheimers Disease (QOL-AD) is a widely used scale for the study of quality of life in patients with dementia. The aim of this study is the transcultural adaptation and validation of the QOL-AD scale in Portugal. METHODS Translation and transcultural adaptation was performed according to state-of-the-art recommendations. For the validation study, 104 patient/caregiver pairs were enrolled. Patients had mild cognitive impairment or mild-to-moderate dementia (due to Alzheimers disease or vascular dementia). Participants were recruited in a dementia outpatient clinic setting and a long-term care dementia ward. An additional comparison group of 22 patients without cognitive impairment, and their proxies, was recruited in a family practice outpatient clinic. Sociodemographic information on patients and caregivers was obtained. Acceptability, reliability, and construct validity were analyzed. RESULTS Internal consistency of the Portuguese version of QOL-AD was good for both patient and caregiver report (Cronbachs α = 0.867 and 0.858, respectively). Construct validity was confirmed by the correlation of patient reported QOL-AD with patient geriatric depression scale scores (ρ = -0.702, p < 0.001) and satisfaction with life scale scores (ρ = 0.543, p < 0.001). Caregiver ratings were correlated with neuropsychiatric inventory (NPI) total score (ρ = -0.404, p < 0.001), NPI-distress (ρ = -0.346, p < 0.001), and patient Mini-Mental State Examination (ρ = 0.319, p < 0.01). QOL-AD patient ratings were higher than caregiver ratings (p < 0.001). Both patient- and caregiver-rated QOL-AD scores were lower in patients with cognitive impairment than in the comparison group without cognitive impairment (p < 0.01). CONCLUSIONS A Portuguese version of QOL-AD with consistent psychometric properties was obtained and is proposed as a useful tool for research and clinical purposes.

Psicoeducação familiar na demência: da clínica à saúde pública

Resumo Introducao Com o envelhecimento populacional e o impacto decorrente nas familias, a demencia tem vindo a adquirir um estatuto de grave problema de saude publica. No quotidiano dos servicos de saude, os aspectos familiares da demencia sao motivo frequente de apresentacao clinica. Contudo, nesses mesmos servicos ou na comunidade, as necessidades das familias sao frequentemente subavaliadas ou nao cobertas. Neste trabalho descrevemos as intervencoes familiares na demencia, revendo especificamente a eficacia e a efectividade da psicoeducacao familiar. Metodos Procedemos a uma revisao narrativa, nao sistematica, da literatura relevante. Resultados Existem diversas formas de intervencao familiar na demencia, dirigidas a familiares-cuidadores (com pendor psicoeducativo ou de apoio emocional) ou com foco sistemico, na linha da terapia familiar. Independentemente do seu caracter predominantemente clinico, todas elas podem ser perspectivadas na interface da promocao da saude. A psicoeducacao familiar visa, em especifico, desenvolver conhecimentos e competencias para lidar com o quadro demencial, diminuindo os niveis de “stress” na familia, podendo eventualmente incidir na saude mental positiva dos cuidadores. Conclusoes Muitas estrategias de prevencao primaria, secundaria ou terciaria nas demencias seriam potenciadas pela literacia em saude, a nivel populacional, nos conteudos relacionados com as doencas associadas ao envelhecimento.

A randomized trial to assess the efficacy of a psychoeducational intervention on caregiver burden in schizophrenia.

BACKGROUND Patients relatives usually care for patients with schizophrenia, and as informal caregivers they experience negative consequences. The aim of the EDUCA-III trial is to test the efficacy of a psychoeducational intervention program (PIP) versus standard care to reduce the caregiver burden at post-intervention (4 months), and at follow-up (8 months). METHOD A two-arm, evaluator blind, multicentre, randomized controlled trial. The PIP group had 12 weekly group sessions. The control intervention group had the usual support and standard care. Primary outcomes were change scores since baseline on the Zarit Burden Interview (ZBI) and the Involvement Evaluation Questionnaire (IEQ). RESULTS One hundred and nine caregivers were randomized to PIP and 114 to control condition from 23 research sites. The decrease of ZBI scores was significantly higher on the PIP arm at 4 months (mean difference [MD]=-4.33; 95% CI -7.96, -0.71), and at 8 months (MD=-4.46; 95% CI -7.79, -1.13). There were no significant decreases in the IEQ scores (MD at 4 months=-2.80; 95% CI -6.27, 0.67; MD at 8 months=-2.85; 95% CI -6.51, 0.81). CONCLUSIONS The PIP condition seems to reduce caregiver burden. TRIAL REGISTRATION ISRCTN32545295.

Needs and quality of life of people with middle-stage dementia and their family carers from the European Actifcare study. When informal care alone may not suffice

ABSTRACT Objective: The Actifcare (Access to timely formal care) study investigated needs of people with dementia and their families during the phase in which formal care is being considered, and examined whether higher need levels are related to lower quality of life (QOL). Method: From eight European countries 451 people with dementia and their carers participated. Needs were measured with the Camberwell Assessment of Need for the Elderly. QOL was measured with the QOL-AD, and carer quality of life was measured with the CarerQol. The relationship between needs and QOL was analysed with multiple regression analyses. Results: Needs were expressed in the domains of psychological distress, daytime activities, company and information. People with dementia rated their unmet needs significantly lower than their carers: the mean number of self-rated unmet needs was 0.95, whereas the mean proxy ratings were 1.66. For met needs, the self-rated mean was 5.5 and was 8 when proxy-rated. The level of needs reported was negatively associated with QOL for both. Conclusion: The study results show that informal carers reported almost twice as many needs as people with dementia. The domains in which needs are expressed should be the primary focus for interventions to support QOL. The perspectives of people with dementia are informative when identifying needs.

Key Elements of a Family Intervention for Schizophrenia: A Qualitative Analysis of an RCT

Schizophrenia is a complex biopsychosocial condition in which expressed emotion in family members is a robust predictor of relapse. Not surprisingly, family interventions are remarkably effective and thus recommended in current treatment guidelines. Their key elements seem to be common therapeutic factors, followed by education and coping skills training. However, few studies have explored these key elements and the process of the intervention itself. We conducted a qualitative and quantitative analysis of the records from a pioneering family intervention trial addressing expressed emotion, published by Leff and colleagues four decades ago. Records were analyzed into categories and data explored using descriptive statistics. This was complemented by a narrative evaluation using an inductive approach based on emotional markers and markers of change. The most used strategies in the intervention were addressing needs, followed by coping skills enhancement, advice, and emotional support. Dealing with overinvolvement and reframing were the next most frequent. Single-family home sessions seemed to augment the therapeutic work conducted in family groups. Overall the intervention seemed to promote cognitive and emotional change in the participants, and therapists were sensitive to the emotional trajectory of each subject. On the basis of our findings, we developed a longitudinal framework for better understanding the process of this treatment approach.

Barriers and facilitators to the access to and use of formal dementia care: findings of a focus group study with people with dementia, informal carers and health and social care professionals in eight European countries

BackgroundPeople with dementia and informal carers often access formal care late in the process of dementia. The barriers and facilitators to service use from the perspectives of different stakeholders involved are not well understood. Thus, we aimed to explore the barriers and facilitators of access to and utilisation of formal care from the perspectives of people with dementia, their informal carers and health and social care professionals.MethodFocus groups with people with dementia, informal carers and professionals were conducted in eight European countries. Recruitment targeted people with dementia, informal carers with experience of formal care and professionals involved in providing (access to) formal care. Qualitative content analysis using open coding was used on a national level. Cross-national synthesis was based on the translated national reports.ResultsOverall, 55 focus groups with 261 participants were conducted, involving 51 people with dementia, 96 informal carers and 114 professionals. Sixteen categories describing barriers and facilitators were identified, referring to three global themes: Aspects related to 1) individuals involved, 2) the system or 3) overarching aspects. The attitudes and beliefs of people with dementia and their carers may have a major impact, and they often serve as barriers. Formal care was perceived as a threat to the individual independence of people with dementia and was thus avoided as long as possible. A healthcare professional serving as a constant key contact person could be an essential facilitator to overcome these barriers. Contact should be initiated proactively, as early as possible, and a trusting and consistent relationship needs to be established. Beyond that, the findings largely confirm former research and show that barriers to accessing and using formal care still exist across Europe despite a number of national and European initiatives.ConclusionFurther investigations are needed to elaborate how the concept of a key contact person could be integrated with existing case management approaches and how the independence and autonomy of people with dementia can be strengthened when formal care needs to be accessed and used. These may be meaningful facilitators regarding enhanced access to formal care for people with dementia and their families.

Neuropsychiatric Symptoms in Cognitive Impairment and Dementia: A Brief Introductory Overview

Neuropsychiatric symptoms in cognitive impairment mainly include the so-called “behavioral and psychological symptoms of dementia”. This designation and the corresponding abbreviation (BPSD) were coined by influential consensus conferences convened by the International Psychogeriatric Association (IPA) in 1996 and 1999. BPSD were defined as “symptoms of disturbed perception, thought content, mood or behavior that frequently occur in patients with dementia.” In this overview, we briefly discuss different models of dementia, along with current neurobiological and psychosocial perspectives. Dementia is bio-psycho-social in nature, and the needs of persons with dementia and their families often require complex health and social care. Therefore, multidisciplinary collaborations should be improved and disseminated.

Family Issues in Behavioral and Psychological Symptoms of Dementia: Unraveling Circular Pathways?

Family issues are at the heart of biopsychosocial and systemic approaches to the way we understand and manage dementia. Based on evidence and clinical experience, this chapter revisits the circularities involving behavioral and psychological symptoms of dementia (BPSD) and the family. Negative and positive consequences of the caregiving experience are considered within the particular context of BPSD. We then analyze some of the “appalling dangers of family life” – i.e., negative ways in which family determinants, including expressed emotion, may impact BPSD. We see that these do not overshadow the family’s role as the most powerful resource throughout the disease. Although further research is needed, both directions of causality ought to be considered in clinical situations: the principle of circularity, as described by the Milan School of Family Therapy, is a heuristic assumption regarding part of the overall BPSD picture. This is discussed at the end of the chapter, together with examples of mediator or modulator variables such as personality and relationship quality, which deserve further exploration.