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Dementia
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In patients over 65 years of age a high level of clinical awareness of the symptoms of depression and dementia should be maintained. These may be opportunistically assessed using questions addressed to the patient and/or their carer (C).
(Depression & Dementia) They may coexist and need differential diagnosis. Routine screening is not recommended because of the absence of evidence of benefit.
The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routine screening for dementia in older adults. (I)
Patients 18 years and above should be assessed for depression opportunistically provided there is effective treatment and follow up (B)
People at high risk for depression should be provided with high level of awareness for depressive symptoms at every encounter. As well they should be screened for depression and offered effective management and follow up every 12 months (B).
People at increased risk for depression should be provided with high level of awareness for depressive symptoms at every encounter. As well they should be screened for depression and offered effective management and follow up opportunistically (C).
The U.S. Preventive Services Task Force (USPSTF) recommends screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up. (B)
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Clinical Considerations
- When the Mini-Mental Status Examination (MMSE) is used to screen unselected patients, the predictive value of a positive result is only fair. The accuracy of the MMSE depends upon a person’s age and educational level: using an arbitrary cut-off point may potentially lead to more false-positives among older people with lower educational levels, and more false-negatives among younger people with higher educational levels.
- Tests that assess functional limitations rather than cognitive impairment, such as the Functional Activities Questionnaire (FAQ) (see Appendix IX) can detect dementia with sensitivity & specificity comparable to that of the MMSE.
- Early recognition of cognitive impairment, in addition to helping make diagnostic and treatment decisions, allows clinicians to anticipate problems the patients may have in understanding.
- Although current evidence does not support routine screening of patients in whom cognitive impairment is not otherwise suspected, clinicians should assess cognitive function whenever cognitive impairment or deterioration is suspected, based on direct observation, patient report, or concerns raised by family members, friends, or care providers.
Intervention and Technique
Case finding and confirmation
- Ask: ‘How is your memory?’ Obtain information from others who know the patient
- Take history from patient and family-carer
- Do complete physical examination over several consultations and functional assessment
- Preventive action if early dementia is suspected
- Regular assessment over time - months or years
Up
Depression
Clinical Considerations
- Many formal screening tools are available (e.g., the Zung Self-Assessment Depression Scale, Beck Depression Inventory, General Health Questionnaire [GHQ], Center for Epidemiologic Study Depression Scale [CES-D]). Asking 2 simple questions (refer to Quick screening below) and anhedonia (Refer to technique below) may be as effective as using longer instruments. There is little evidence to recommend one screening method over another, so clinicians can choose the method that best fits their personal preference, the patient population served, and the practice setting.
- All positive screening tests should trigger full diagnostic interviews that use standard diagnostic criteria (refer to Mental Health Guidelines).
- Many risk factors for depression (e.g., female sex, family history of depression, unemployment, and chronic disease) are common, but the presence of a risk factor alone cannot distinguish depressed from nondepressed patients.
- The optimal interval for screening is unknown. Recurrent screening may be most productive in patients with a history of depression, unexplained somatic symptoms, comorbid psychological conditions (e.g., panic disorder or generalized anxiety), substance abuse, or chronic pain.
- Clinical practices that screen for depression should have systems in place to ensure that positive screening results are followed by accurate diagnosis, effective treatment, and careful follow up. Benefits from screening are unlikely to be realized unless such systems are functioning well.
- Treatment may include antidepressants or specific psychotherapeutic approaches (e.g., cognitive behavioral therapy or brief psychosocial counseling), alone or in combination.
- The benefits of routinely screening children and adolescents for depression are not known. The existing literature suggests that screening tests perform reasonably well in adolescents and that treatments are effective, but the clinical impact of routine depression screening has not been studied in pediatric populations in primary care settings. Clinicians should remain alert for possible signs of depression in younger patients. The predictive value of positive screening tests is lower in children and adolescents than in adults, and research on the effectiveness of primary care-based interventions for depression in this age group is limited.
- Major depression is a treatable cause of pain, suffering, disability and death, yet primary care providers detect major depression in only 1/3 to 1/2 of their patients with major depression (Schonfeld, 1997; Williams Jr, 2002).
- Patients with a history of mood disorders are at increased risk for postpartum depression. Post partum blues affect 50-85% of mothers in the first two weeks after delivery. The first two to three months postpartum is the period of greatest risk for the development of major depression.
Quick Screening Test
- “Over the past 2 weeks, have you felt down, depressed, or hopeless?” (B)
- “Over the past 2 weeks, have you ever felt less interest or pleasure in doing things?” (B)
- If the patient answers "yes" to either one of the above questions, consider using a quantitative questionnaire to further assess whether the patient has sufficient symptoms to warrant a diagnosis of major depression and a full clinical interview.
Risk of Dementia and Depression
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Who is at higher risk of
Dementia and Depression?
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What should be done?
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How often?
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Average risk
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Those without symptoms
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No evidence of benefit from screening
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NA
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Increased risk
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• Family history of Alzheimer's disease
• patients with repeated history of head trauma
• patients with Down syndrome
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Case finding and early disease intervention
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NA
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High risk
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• those presenting with anxiety, memory impairment, or depression
• past history of depression
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Case find if suspected, as early intervention, comprehensive assessment and support helps Patients who complain of memory loss are more likely to have depression than dementia
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Opportunistically
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