A practical approach to detection and treatment of depression in Parkinson disease and dementia

Abstract

Purpose of review: To review the available evidence for the detection and management of depression in Parkinson disease (PD) and dementia.

Recent findings: Depression is a common comorbidity in those with PD or dementia, and leads to increased morbidity. There are several available and accurate tools for the detection of depression in PD (e.g., Geriatric Depression Scale) and dementia (e.g., Cornell Scale for Depression in Dementia). Treatment of depression depends on patient preference, severity of depression, comorbidities, and available resources. Despite variable evidence, the use of nonpharmacologic strategies to manage depression is suggested. Pharmacologic management is guided by modest evidence in PD and dementia, but also informed by the management of late-life depression (LLD).

Summary: There is evidence to guide the diagnosis and management of depression in PD or dementia. However, more research is required in this field to better inform clinical decision-making.

Figure 1. An approach to the initial screening, diagnosis, and workup of depression in Parkinson disease (PD) or dementia

CSDD = Cornell Scale for Depression in Dementia; GDS = Geriatric Depression Scale; HCP = health care provider; HDRS = Hamilton Depression Rating Scale.

Figure 2. Treatment algorithm

This algorithm is a suggested approach looking at the available evidence in dementia and Parkinson disease (PD) and the evidence available for prescribing in late-life depression in the 2016 CANMAT guidelines. All of the above drugs have side effects, drug–drug interactions, and drug–disease interactions. When choosing an agent, it is important to be informed of these, and how they apply to the patient. All these concerns need to be discussed with the patient to allow the patient to make an informed decision and express his or her preference. Consider drug initiation at the lowest possible dose, with slow titration. ^aDue to limited evidence in dementia, one must consider agents that do not have robust evidence; however, the results demonstrate safety for the use of sertraline or mirtazapine. ^bIn PD, tricyclic antidepressants demonstrated more benefit to mood, but at the risk of worsening motor symptoms. As such, the current recommendation is to consider selective serotonin reuptake inhibitors (SSRIs) or mirtazapine first line.^{,,, c}No explicit evidence in dementia or PD, but there is evidence in late-life depression. ^dPrior to changing medication, evaluate for medication adherence, tolerability, and side effects. ^eAugmenting agents should be used with caution; consider expert consultation. Lithium has been shown to have adverse effects and is not recommended in PD. ^fAugmenting agents should be used with caution; consider expert consultation. Methylphenidate is associated with adverse effects, such as agitation in dementia.SNRI = serotonin and norepinephrine reuptake inhibitor.