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Problem adaptation therapy for older adults with major depression and cognitive impairment: a randomized clinical trial.

ABSTRACT: IMPORTANCE:Problem adaptation therapy (PATH) is a treatment for older adults with major depression, cognitive impairment (from mild cognitive deficits to moderate dementia), and disability. Antidepressants have limited efficacy in this population and psychosocial interventions are inadequately investigated. OBJECTIVE:To test the efficacy of 12-week PATH vs supportive therapy for cognitively impaired patients (ST-CI) in reducing depression and disability in 74 older adults with major depression, cognitive impairment, and disability. DESIGN, SETTING, AND PARTICIPANTS:A randomized clinical trial at the Weill Cornell Institute of Geriatric Psychiatry from April 1, 2006, to September 31, 2011. Interventions were administered at the participants' homes. Participants included 74 older individuals (age ? 65 years) with major depression and cognitive impairment to the level of moderate dementia. They were recruited through collaborating community agencies of Weill Cornell Institute of Geriatric Psychiatry and were randomly assigned to 12 weekly sessions of PATH or ST-CI (14.8% attrition rate). INTERVENTIONS:Home-delivered PATH vs home-delivered ST-CI. Problem adaptation therapy integrates a problem-solving approach with compensatory strategies, environmental adaptations, and caregiver participation to improve patients' emotion regulation. Supportive therapy for cognitively impaired patients focuses on expression of affect, understanding, and empathy. MAIN OUTCOMES AND MEASURES:Mixed-effects models for longitudinal data compared the efficacy of PATH with that of ST-CI in reducing depression (Montgomery-Asberg Depression Rating Scale) and disability (World Health Organization Disability Assessment Schedule II) during 12 weeks of treatment. RESULTS:Participants in PATH had significantly greater reduction in depression (Cohen d, 0.60; 95% CI, 0.13-1.06; treatment × time, F(1,179) = 8.03; P =?.005) and disability (Cohen d, 0.67; 95% CI, 0.20-1.14; treatment × time, F(1,169) = 14.86; P =?.001) than ST-CI participants during the 12-week period (primary outcomes). Furthermore, PATH participants had significantly greater depression remission rates than ST-CI participants (37.84% vs 13.51%; ?(2) = 5.74; P =?.02; number needed to treat = 4.11) (secondary outcome). CONCLUSIONS AND RELEVANCE:Problem adaptation therapy was more efficacious than ST-CI in reducing depression and disability. Problem adaptation therapy may provide relief to a large group of depressed and cognitively impaired older adults who have few treatment options. TRIALS REGISTRATION:Clinicaltrials.gov Identifier: NCT00368940.

SUBMITTER: Kiosses DN

PROVIDER: S-EPMC4583822 | biostudies-literature | 2015 Jan

REPOSITORIES: biostudies-literature

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Problem adaptation therapy for older adults with major depression and cognitive impairment: a randomized clinical trial.

Kiosses Dimitris N DN Ravdin Lisa D LD Gross James J JJ Raue Patrick P Kotbi Nabil N Alexopoulos George S GS

JAMA psychiatry 20150101 1

<h4>Importance</h4>Problem adaptation therapy (PATH) is a treatment for older adults with major depression, cognitive impairment (from mild cognitive deficits to moderate dementia), and disability. Antidepressants have limited efficacy in this population and psychosocial interventions are inadequately investigated.<h4>Objective</h4>To test the efficacy of 12-week PATH vs supportive therapy for cognitively impaired patients (ST-CI) in reducing depression and disability in 74 older adults with maj ...[more]

PMID: 25372657

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Project description:OBJECTIVES:Antidepressants have limited efficacy in older adults with depression and cognitive impairment, and psychosocial interventions for this population have been inadequately investigated. Problem Adaptation Therapy (PATH) is a psychosocial intervention for older adults with major depression, cognitive impairment, and disability. DESIGN:This study tests the efficacy of PATH versus Supportive Therapy for Cognitively Impaired Older Adults (ST-CI) in reducing depression (Montgamery Asberg Depression Rating Scale [MADRS]) and disability (World Health Organization Disability Assessments Schedule-II [WHODAS-II]) and improving cognitive outcomes (Mini Mental State Examination [MMSE]) over 24 weeks (12 weeks of treatment and 12-week post-treatment follow-up). SETTING:Participants were recruited through collaborating community agencies of Weill Cornell Institute of Geriatric Psychiatry. Both interventions and all research assessments were conducted at home. PARTICIPANTS:Thirty-five older adults (age ? 65 years) with major depression and cognitive impairment no dementia (CIND). INTERVENTIONS:PATH aims to increase emotion regulation by incorporating a problem-solving approach, teaching compensatory strategies, and inviting caregiver participation. Supportive Therapy aims to facilitate the expression of affect, as well as promote empathy. MEASUREMENTS:Depression was measured using the MADRS, disability using the WHODAS-II, and cognition using the MMSE. RESULTS:PATH participants showed significantly greater reduction in MADRS total score (7.04 points at 24 weeks, treatment group by time interaction: F[1,24.4] = 7.61, p = 0.0108), greater improvement in MMSE total score (2.30 points at 24 weeks, treatment group by time interaction: F[1,39.8] = 13.31, p = 0.0008), and greater improvement in WHODAS-II total score (2.95 points at 24 weeks, treatment group by time interaction: F[1,89] = 4.93, p = 0.0290) than ST-CI participants over the 24-week period. CONCLUSIONS:PATH participants had better depression, cognitive, and disability outcomes than ST-CI participants over 6 months. PATH may provide relief to depressed older adults with CIND who currently have limited treatment options.

Project description:ContextOlder patients with depression and executive dysfunction represent a population with significant disability and a high likelihood of failing pharmacotherapy.ObjectivesTo examine whether problem-solving therapy (PST) reduces disability more than does supportive therapy (ST) in older patients with depression and executive dysfunction and whether this effect is mediated by improvement in depressive symptoms.DesignRandomized controlled trial.SettingWeill Cornell Medical College and University of California at San Francisco.ParticipantsAdults (aged >59 years) with major depression and executive dysfunction recruited between December 2002 and November 2007 and followed up for 36 weeks. Intervention Twelve sessions of PST modified for older depressed adults with executive impairment or ST. Main Outcome Measure Disability as quantified using the 12-item World Health Organization Disability Assessment Schedule II.ResultsOf 653 individuals referred to this study, 221 met the inclusion criteria and were randomized to receive PST or ST. Both PST and ST led to comparable improvement in disability in the first 6 weeks of treatment, but a more prominent reduction was noted in PST participants at weeks 9 and 12. The difference between PST and ST was greater in patients with greater cognitive impairment and more previous episodes. Reduction in disability paralleled reduction in depressive symptoms. The therapeutic advantage of PST over ST in reducing depression was, in part, due to greater reduction in disability by PST. Although disability increased during the 24 weeks after the end of treatment, the advantage of PST over ST was retained.ConclusionsThese results suggest that PST is more effective than ST in reducing disability in older patients with major depression and executive dysfunction, and its benefits were retained after the end of treatment. The clinical value of this finding is that PST may be a treatment alternative in an older patient population likely to be resistant to pharmacotherapy.Trial registrationclinicaltrials.gov Identifier: NCT00052091.

Project description:BackgroundTo examine the effect of multicomponent exercise program on memory function in older adults with mild cognitive impairment (MCI), and identify biomarkers associated with improvement of cognitive functions.Methodology/principal findingsSubjects were 100 older adults (mean age, 75 years) with MCI. The subjects were classified to an amnestic MCI group (n?=?50) with neuroimaging measures, and other MCI group (n?=?50) before the randomization. Subjects in each group were randomized to either a multicomponent exercise or an education control group using a ratio of 1?1. The exercise group exercised for 90 min/d, 2 d/wk, 40 times for 6 months. The exercise program was conducted under multitask conditions to stimulate attention and memory. The control group attended two education classes. A repeated-measures ANOVA revealed that no group × time interactions on the cognitive tests and brain atrophy in MCI patients. A sub-analysis of amnestic MCI patients for group × time interactions revealed that the exercise group exhibited significantly better Mini-Mental State Examination (p?=?.04) and logical memory scores (p?=?.04), and reducing whole brain cortical atrophy (p<.05) compared to the control group. Low total cholesterol levels before the intervention were associated with an improvement of logical memory scores (p<.05), and a higher level of brain-derived neurotrophic factor was significantly related to improved ADAS-cog scores (p<.05).Conclusions/significanceThe results suggested that an exercise intervention is beneficial for improving logical memory and maintaining general cognitive function and reducing whole brain cortical atrophy in older adults with amnestic MCI. Low total cholesterol and higher brain-derived neurotrophic factor may predict improvement of cognitive functions in older adults with MCI. Further studies are required to determine the positive effects of exercise on cognitive function in older adults with MCI.Trial registrationUMIN-CTR UMIN000003662 ctr.cgi&quest;function&hairsp;=&hairsp;brows&action&hairsp;=&hairsp;brows&type&hairsp;=&hairsp;summary&recptno&hairsp;=&hairsp;R000004436&language&hairsp;=&hairsp;J.

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Problem adaptation therapy for older adults with major depression and cognitive impairment: a randomized clinical trial.

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Problem adaptation therapy for older adults with major depression and cognitive impairment: a randomized clinical trial.

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