Objective: Cognitive impairment is often a central feature of depression in late life as well as an early sign of dementia. With demographic projections predicting the fastest growth of those over 85 years of age, innovative treatment strategies are therefore a high priority to manage increasing numbers of individuals who have depression and concomitant cognitive impairment. Our experience in the Maintenance Therapies in Late Life Depression (MTLD-II) study demonstrated that more than half of our depressed subjects over age 70 showed evidence of cognitive impairment. Depressed, geriatric aged subjects with cognitive impairment were more likely to be non-compliant with their medication due to forgetfulness or misunderstood directions. Problem solving ability declined with increasing cognitive impairment which is one factor that leads to demoralization and depression. Due to memory impairment and/or a decline in intellectual capacity, the ability of this subgroup of depressed elders to use insight in traditional psychotherapy or build upon prior therapeutic gains may be impaired, thus limiting any potential benefit from the application of traditional psychotherapies.
Design: Subjects over age 70 with major depression and MMSE scores between 18 and 30, were treated with paroxetine and weekly IPT sessions. Weekly Hamilton Rating Scale scores were recorded. Remitted subjects who remained stable for 16 weeks were randomized for 2 years of monthly follow up to drug or PBO and IPT or Clinical Management (4 cells).
Methods: Therapists’ 5 point Likert ratings of IPT integrity were obtained for each session by rating the subject’s ability to engage in therapy, maintain a focus for treatment, and recall pertinent clinical material from prior sessions. Data presented here is limited to the acute and continuation phases of the study. Subjects were grouped by Mattis Dementia Rating Scale Scores in 3 groups: those with no dementia, mild dementia and moderate dementia (MDRS Scores >130, 120-130, and <120 respectively). Chi squared analyses were used between groups.
Results: The subjects' ability to engage, focus and recall all declined steadily with worsening cognitive function (p<0.005); however, there was no statistical difference in response rates (maintaining a HRS score of 10 or less for 3 consecutive weeks) between groups or time to response.
Conclusion: Response rates may reflect an overwhelming effect of drugs in this combination study. Alternatively, attempts to provide IPT to more cognitively impaired subjects may have succeeded as a variation of supportive psychotherapy. The involvement of caregivers in treatment, alternative techniques and the implication of these findings will be discussed.
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