Le problematiche emozionali del paziente con MdA e del caregiver

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1 Fondazione Arturo Pinna Pintor La diagnosi precoce della Malattia di Alzheimer: un obiettivo strategico per la medicina del XXI secolo Torino 19 ottobre 2013 Le problematiche emozionali del paziente con MdA e del caregiver Riccardo Torta SCDU Psicologia Clinica e Oncologica Dipartimento di Neuroscienze Università di Torino

2 shared pathogenic factors cognitive affectivity depressive pseudodementia cognitive cluster of depression bridge symptoms masqued cognitive depression

3 cognition pseudo-dementia cognitive disorders depression psychoses mood disruptive behaviours behaviour BPSD

4 Neuropsychological aspects Amnesia Aphasia Agnosia Apraxia Non cognitive symptoms Behavioural disturbances Chronic stress Mood depression Anxiety Functional status

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6 Diagnosi differenziale Depressione maggiore senza demenza depressione in corso di demenza depressione e demenza pseudo-demenzademenza depressiva Demenza senza depressione comorbilit ità DEPRESSIONE sintomi cognitivi substrato biologico sintomi depressivi DEMENZA

7 patients suffering from depression with severe cognitive impairment (pseudodementia/ depression of dementia), were at a much higher risk of developing real dementia than those depressed without the high level of cognitive impairment The concept was that depression may be a kind of stress test that will expose inherited weaknesses in brain function

8 Mood Depression and Alzheimer Disease: consequences for patient and caregiver advanced institutionalization worsening of quality of life higher disability higher aggressiveness higher caregiver burden higher mortality Lee & Lyketsos, 2003; Torta e Caltagirone, 2006

9 dysphoric mood irritability loss of interest lost of pleasure confounding aspects psychomotor changes AFFECTIVE impaired concentration Impaired decision making BEHAVIOURAL DEPRESSIVE CLUSTERS COGNITIVE coping styles alterations in appetite weight sleep patterns sexual desire SOMATIC impaired memory cognitive distortion increased fatigue headaches other chronic pains 9

10 BPSD Neurotransmitter basis Apathy Withdrawn Lack of interest Amotivation Depression Aggression Aggressive resistance Physical aggression Verbal aggression Sad Tearful Hopeless Low self esteem Anxiety Guilt Hallucinations Delusions Misidentifications Psychomotor agitation Walking aimlessly Pacing Trailing Restlessness Repetitive actions Dressing/undressing Sleep disturbance Psychosis

11 Brain metabolism in dementia: relationship to symptomatology Apathy Psychosis Subjective mood symptoms Frontal High pole Prefrontal Frontal Anterior cingulate Low Parietal Anxiety/depression Agitation/ disinhibition Temporal Delusional thoughts (hypometabolism) Sultzer DL. et al 1996 Galynker et al., 2000

12 Behavioral disorders and Alzheimer Disease progression Prevalenza (% di pazienti) Suicidal Ideation Depression Social Withdrawal Paranoia Diurnal Rhythm Anxiety Accusatory Irritability Mood Change Agitation Wandering Aggression Hallucinations Socially Unacceptable Delusions Sexually Inappropriate Months before diagnosis Months after diagnosis Grossberg, 2002

13 psychosis Depressione e Malattia di Alzheimer Modificazione dei Sintomi (%) nel Tempo aggression AD, non depressi AD, depressi (n=33) (n=15) anno 1 anno 3 anno 1 anno 3 - Depressione Perdita di interesse Perdita di energia Ridotta autostima agitation Colpa Ideazione suicidaria Ridotta concentrazione Rallentamento Agitazione Difficoltà a dormire Risveglio precoce Ridotto appetito Cambiamenti di umore depression anxiety Ritchie et al, 1999

14 Mood Depression and Alzheimer Disease: diagnostic problems Atypical depressive pictures Shortness of severe episodes (days) Symptoms overlap Symptoms changing from time to time Reduced awareness / symptoms expression Bias for caregiver depression Lyketsos & Lee, 2004, Torta and Caltagirone, 2006

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17 Diagnosi differenziale Depressione maggiore senza demenza depressione in corso di demenza depressione e demenza pseudo-demenzademenza depressiva Demenza senza depressione comorbilit ità DEPRESSIONE sintomi cognitivi substrato biologico sintomi depressivi DEMENZA

18 Mood depression and cognition pathogenic factors sharing neurotransmitters hormons Serotonin Noradrenaline Dopamine Acetylcholine Glutamate HPA axys HPT axys HPG axys citokines IL-1 IL-2 IL-6 TNFα growth factors BDNF NGF GDNF

19 Alzheimer disease ADHD Schizophrenia Aging cognitive decline Dementias Parkinson ADHD Mood depression Chronic stress Mood depression FMS ADHD Mood depression FMS

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21 DT Thermometer

22 DT scores correlated with the activity of brain areas typically involved in stress response. Indeed, hypothalamus metabolism was found to be the best predictor of distressed patients. Metabolic correlates of Distress Thermometer. In light grey with black border areas whose activity correlates positively with DT scores. Problem Checklist: In light grey with black border areas whose activity correlates positively with Physical Problems scores, in grey areas whose activity correlates positively with Emotional Problems scores, in black amygdala.

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24 The involvement of frontal lobes could be a factor guiding the changes and the adaptation mechanisms activated as a response by the system (e.g. cytokines production, stress system activation, immune system responses). High cytokines levels correlate with mood depression, cognitive dysfunction, pain and stress levels

25 Long-term inflammatory processes. HPA axis dysfunction, chronic inflammation, and a deficit in neurotrophin signaling all may play roles in the pathogenesis of depression and Alzheimer disease.

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28 Alzheimer s disease affects an estimated 5.4 million people and 14.9 million unpaid caregivers exist in the United States (American Alzheimer s Association, 2011) Eighty percent of care provided at home is delivered by family caregivers long lasting stress cardiovascular system alterations immune system alterations Caregivers experiencing emotional or physical strain have a 63% of greater mortality than noncaregivers (Lutgendorf et al., 2009).

29 Stress, Anxiety, and Depression were positively correlated with : caring hours and sleep problems in the caregiver behavioral disturbances of the patient

30 individual ability to cope succesfully with a stressful situation Resilience Come si può intervenire sullo stress? temperament stressor s load experience comeback strategies

31 Volontarie (donne) attivano le loro aree affettive del dolore (corteccia cingolata anteriore ACC) quando osservano I loro amati che ricevono una (finta) stimolazione dolorosa sulla mano Più è alto il punteggio alle scale di empatia, tanto più si attivano le aree affettive del dolore

32 continous dedication compassion fatigue loss of socialization disease unfavourable prognosis behavioral disturbances agitation/confusion relation factors terapies Ineffectiveness side effects costs temperament coping style comeback abilities emotional and physical status caregiver Burn-out in caregiving

33 Take home messages High prevalence of emotional disorders in Alzheimer patient s and their caregivers Depressive symptoms change during the course of disease Mood Depression and cognitive disorders show a pathogenetic overlap Caregivers can have an high level of emotional and somatic pathologies (need of care)