Poststroke psychosis: a systematic review

A preregistered systematic review of poststroke psychosis examining clinical characteristics, prevalence, diagnostic procedures, lesion location, treatments, risk factors and outcome. Neuropsychiatric outcomes following stroke are common and severely impact quality of life. No previous reviews have focused on poststroke psychosis despite clear clinical need. CINAHL, MEDLINE and PsychINFO were searched for studies on poststroke psychosis published between 1975 and 2016. Reviewers independently selected studies for inclusion, extracted data and rated study quality. Out of 2442 references, 76 met inclusion criteria. Average age for poststroke psychosis was 66.6 years with slightly more males than females affected. Delayed onset was common. Neurological presentation was typical for stroke, but a significant minority had otherwise ‘silent strokes’. The most common psychosis was delusional disorder, followed by schizophrenia-like psychosis and mood disorder with psychotic features. Estimated delusion prevalence was 4.67% (95% CI 2.30% to 7.79%) and hallucinations 5.05% (95% CI 1.84% to 9.65%). Twelve-year incidence was 6.7%. No systematic treatment studies were found. Case studies frequently report symptom remission after antipsychotics, but serious concerns about under-representation of poor outcome remain. Lesions were typically right hemisphere, particularly frontal, temporal and parietal regions, and the right caudate nucleus. In general, poststroke psychosis was associated with poor functional outcomes and high mortality. Poor methodological quality of studies was a significant limitation. Psychosis considerably adds to illness burden of stroke. Delayed onset suggests a window for early intervention. Studies on the safety and efficacy of antipsychotics in this population are urgently needed

Investigation of possible risk factors for depression in Alzheimer's disease: A systematic review of the evidence

Background: Depression is common in people with Alzheimer's disease (AD), and is associated with increased risk of institutionalization and mortality. Understanding risk factors for depression in AD is key to its development and treatment. / Methods: We searched the MEDLINE, EMBASE, PsycINFO, and CINAL databases for longitudinal prospective cohort studies that evaluated risk factors for depression in people with AD. Two authors independently selected articles for inclusion and assessed quality of studies using predetermined criteria. / Results: In seven studies that met the inclusion criteria, 2029 participants were followed up for a median of 5 years. Gender and educational attainment were not predictors of depression risk. History of a past psychiatric disorder and greater cognitive impairment predicted increased risk of depression in more than one study. In single studies, younger age, having a family history of psychiatric disorder, neuroticism, functional decline, presence of sleep disturbance and aggression, and increased cardiovascular risk predicted depression risk. Not being within 6 months of dementia onset and, counterintuitively having two comorbid disorders were protective factors in one study. / Limitations: A small number of studies exist overall and only a few have examined the same risk factors. Most of the studies have measured depression using scales that are not validated in AD. / Conclusions: These results inform a preliminary model of depression risk in people with AD. Unlike in the general population, men and women and those with higher and lower educational levels of attainment may be equally at risk of depression. Clinicians should be aware of these possible differences in the risk profile for depression in AD populations, to assist detection and enable early treatment. Interventions to delay cognitive and functional decline may reduce depression risk

Psychological treatments for depression and anxiety in dementia and mild cognitive impairment

BACKGROUND: Experiencing anxiety and depression is very common in people with dementia and mild cognitive impairment (MCI). Psychological interventions have been suggested as a potential treatment for these populations. Current research suggests that people with dementia and MCI have limited opportunities for psychological treatments aimed at improving their well-being. A systematic review of the evidence on their effectiveness is likely to be useful in terms of improving outcomes for patients and for future recommendations for practice. OBJECTIVES: The main objective of this review was to assess the effectiveness of psychological interventions in reducing anxiety and depression in people with dementia or mild cognitive impairment (MCI). SEARCH METHODS: We searched the Cochrane Dementia and Cognitive Improvement Group Specialized Register and additional sources for both published and unpublished data. Selection criteria We included randomised controlled trials (RCTs) comparing a psychological intervention with usual care or a placebo intervention (social contact control) in people with dementia or MCI. DATA COLLECTION AND ANALYSIS: Two review authors worked independently to select trials, extract data and assess studies for risk of bias, using a data extraction form. We contacted authors when further information was not available from the published articles. MAIN RESULTS: Six RCTs involving 439 participants with dementia were included in the review, but no studies of participants with MCI were identified. The studies included people with dementia living in the community or in nursing home care and were carried out in several countries. Only one of the studies was classified as low risk of bias. Five studies were at unclear or high risk of bias due to uncertainties around randomisation, blinding and selective reporting of results. The studies used the different psychological approaches of cognitive behavioural therapy (CBT), interpersonal therapy and counselling. Two studies were of multimodal interventions including a specific psychological therapy. The comparison groups received either usual care, attention-control educational programs, diagnostic feedback or services slightly above usual care. Meta-analysis showed a positive effect of psychological treatments on depression (6 trials, 439 participants, standardised mean difference (SMD) -0.22; 95% confidence interval (CI) -0.41 to -0.03, moderate quality evidence) and on clinician-rated anxiety (2 trials, 65 participants, mean difference (MD) -4.57; 95% CI -7.81 to -1.32, low quality evidence), but not on self-rated anxiety (2 trials, SMD 0.05; 95% CI -0.44 to 0.54) or carer-rated anxiety (1 trial, MD -2.40; 95% CI -4.96 to 0.16). Results were compatible with both benefit and harm on the secondary outcomes of patient quality of life, activities of daily living (ADLs), neuropsychiatric symptoms and cognition, or on carers' self-rated depressive symptoms, but most of the studies did not measure these outcomes. There were no reports of adverse events. AUTHORS' CONCLUSIONS: We found evidence that psychological interventions added to usual care can reduce symptoms of depression and clinician-rated anxiety for people with dementia. We conclude that psychological interventions have the potential to improve patient well-being. Further high quality studies are needed to investigate which treatments are most effective and to evaluate the effect of psychological interventions in people with MCI

Minor and subthreshold depressive disorders in Alzheimer's disease: a systematic review and meta-analysis of prevalence studies

Background: Depressive symptoms are common in Alzheimer's disease (AD) and negatively impact patient well-being. The main aim of the present study was to establish summary estimates for the prevalence of minor depressive disorder (MinD) and subthreshold depression in AD and synthesise evidence on prognosis and management of these symptoms in order to inform clinical guidelines. / Methods: Systematic review and meta-analysis of cross-sectional and longitudinal studies of prevalence, prognosis, and treatments for minor and subthreshold depression in AD. We searched MEDLINE, Embase, PsycINFO and CINAHL. We included studies that reported prevalence of subthreshold depressive disorders and those reporting data on validity of diagnostic criteria, mechanisms, or randomised controlled clinical trials (RCTs) testing effectiveness of interventions. Estimates of prevalence were pooled using random-effects meta-analyses. Two authors screened articles and independently extracted data on study characteristics. / Results: We reviewed 5671 abstracts, retrieved 621 full text articles and included a total of 15 studies. Pooling data from 10 studies showed that prevalence for MinD in AD was 22.0% (95% CI 16.0 to 28.0). Prevalence for a clinical diagnosis of MinD (DSM-III-R and DSM-IV) was 26.0% (95% CI 20.0 to 32.0; 6 studies). People with MinD experienced higher levels of neuropsychiatric symptoms, functional and cognitive decline, although studies remain cross-sectional. Neither sertraline nor a carer intervention were effective in reducing symptoms. / Conclusion: This review finds that MinD is prevalent in people with a diagnosis of AD and requires clinical attention. Research is warranted to develop effective interventions to treat and prevent these symptoms

Personality and dementia caring: a review and commentary.

Carers of people with dementia are at increased risk of experiencing psychological distress. This article reviews recent findings on the role of personality traits for psychological outcomes for carers of people with dementia

Life after care: psychological adjustment to bereavement in family carers of people with dementia

BACKGROUND: Despite well-documented evidence of the psychological effects of caring for a relative with dementia, little is known about the bereavement experiences of family carers. The aim of this study was to explore the key psychological changes associated with carers' adjustment to bereavement and "life after care." METHODS: All carers taking part were recruited from a day care center, providing specialist services to people with dementia. We asked carers to describe the key changes associated with psychological adjustment to bereavement through semi-structured qualitative in-depth interviews. Strategies carers used to cope with and adapt to their new role were also explored. All data were thematically analysed. RESULTS: Thirty-one carers were interviewed. The most frequent emotional reactions to bereavement were feelings of loneliness, loss, void, sadness, anger, and relief. Most carers were able to adapt to their new role, and engaging in pleasant activities was the most frequent strategy used to cope with loss and "life after care." CONCLUSIONS: Feelings of loneliness and loss are amongst the key emotional reactions shaping carers' adjustment to bereavement. Most carers are able to adapt to loss; however, a minority experience increased psychological distress after the death of their loved one. A small percentage of carers continues caring for other dependants. Further research is required to identify how carers of people with dementia adapt to bereavement and how this increasing number of individuals can be best supported

IDEA intervention to prevent depressive symptoms and promote well-being in early-stage dementia: protocol for a randomised controlled feasibility study

OBJECTIVE: Depressive symptoms are common among people with dementia, impacting quality of life and cognitive and functional decline. Currently, little is known about the acceptability and feasibility of psychological interventions for people with mild dementia, with recent reviews identifying the need for further evidence. Developing and evaluating psychological interventions to prevent and treat these symptoms is, therefore, an important clinical and research priority. This protocol describes a study testing the acceptability and feasibility of a manual-based behavioural activation (BA) intervention for preventing and treating depressive symptoms in people with mild dementia. The aim of this study is to explore the feasibility of conducting a pragmatic multicentre randomised controlled trial of clinical effectiveness of an eight-session intervention. The Intervention to prevent Depressive symptoms and promote well-being in EArly-stage dementia (IDEA) programme supports people with dementia and their family carers in identifying and scheduling enjoyable and meaningful activities. METHODS AND ANALYSIS: Sixty people who have received a diagnosis of dementia of any type in the last 6 months will be recruited via memory clinics. Further criteria are a Mini-Mental State Examination score of ≥20, and a family carer who can assist with the intervention. Consenting participants will be randomised in a ratio of 2:1 to BA or to treatment as usual. Analyses will estimate parameters such as rates of recruitment, retention and number of sessions completed. Questionnaires measuring depressive symptoms and quality of life for both the person with dementia and their carer will be completed at baseline, 3 and 6 months. Qualitative interviews will explore acceptability of the intervention, study procedures and experiences of the sessions. ETHICS AND DISSEMINATION: This study received a favourable ethical opinion from the London Camberwell St Giles Research Ethics Committee (16/LO/0540). We will disseminate findings at key conferences, the Alzheimer’s Society and University College London websites and local stakeholder events. TRIAL REGISTRATION NUMBER: ISRCTN75503960; Pre-results

The relationship between perceived social support and psychological distress in carers of older relatives: A longitudinal cross-lagged analysis

BACKGROUND AND OBJECTIVES: Although a large body of research has examined the relationship between social support and psychological health of family carers of frail older people, the exact nature and direction of this relationship is not well understood with most research to date being cross-sectional. This longitudinal study explored the relationship between perceived social support and psychological distress in carers of older relatives. METHODS: We used data from two longitudinal cohorts which included a total of 332 family carers of frail older people. We used cross-lagged panel analysis to investigate the longitudinal association between perceived social support and carer psychological distress controlling for a number of covariates over time. RESULTS: Fully-adjusted Generalised Estimating Equations (GEE) and cross-lagged models indicated that higher social support was significantly associated with lower carer psychological distress over time (regression coefficient [B] = -0.178, standard error [SE] = 0.028), with levels of perceived social support exerting an effect on psychological distress rather than vice versa (β = 0.03, p = 0.32). LIMITATIONS: All observations were based on self-report data, and there may be other variables that may explain the results that we did not account for. DISCUSSION AND IMPLICATIONS: Our study finds that the directionality of the relationship appears to be from perceived social support to carer psychological distress suggesting that social support directly affects carer psychological health but not vice versa. This finding has important implications for the provision of social support interventions for carers of frail older people at risk of experiencing psychological distress

Subjective caregiver burden and anxiety in informal caregivers: a systematic review and meta-analysis

There is increasing evidence that subjective caregiver burden is an important determinant of clinically significant anxiety in family carers. This meta-analysis aims to synthesise this evidence and investigate the relationship between subjective caregiver burden and anxiety symptoms in informal caregivers. We searched PubMed, CINAHL and PsycINFO up to January 2020. Combined estimates were obtained using a random-effects model. After screening of 4,312 articles, 74 studies (with 75 independent samples) were included. There was a large, positive association between subjective caregiver burden and anxiety symptoms (r = 0.51; 95% CI = 0.47, 0.54; I2 = 0.0%). No differences were found in subgroup analyses by type of study design (cross-sectional vs. longitudinal), sampling, control of confounders or care-recipient characteristics. Subjective caregiver burden is an important risk factor for anxiety in informal caregivers. Targeting subjective caregiver burden could be beneficial in preventing clinically significant anxiety for the increasing number of family carers worldwide