Comparative efficacy of interventions for reducing symptoms of depression in people with dementia: systematic review and network meta-analysis

Abstract

Objective To describe the comparative efficacy of drug and non-drug interventions for reducing symptoms of depression in people with dementia who experience depression as a neuropsychiatric symptom of dementia or have a diagnosis of a major depressive disorder. Design Systematic review and meta-analysis. Data sources Medline, Embase, the Cochrane Library, CINAHL, PsycINFO, and grey literature between inception and 15 October 2020. Eligibility criteria for study selection Randomised trials comparing drug or non-drug interventions with usual care or any other intervention targeting symptoms of depression in people with dementia. Main outcome measures Pairs of reviewers screened studies, abstracted aggregate level data, and appraised risk of bias with the Cochrane risk of bias tool, which facilitated the derivation of standardised mean differences and back transformed mean differences (on the Cornell scale for depression in dementia) from bayesian random effects network meta-analyses and pairwise meta-analyses. Results Of 22 138 citations screened, 256 studies (28 483 people with dementia) were included. Missing data posed the greatest risk to review findings. In the network meta-analysis of studies including people with dementia without a diagnosis of a major depressive disorder who were experiencing symptoms of depression (213 studies; 25 177 people with dementia; between study variance 0.23), seven interventions were associated with a greater reduction in symptoms of depression compared with usual care: cognitive stimulation (mean difference −2.93, 95% credible interval −4.35 to −1.52), cognitive stimulation combined with a cholinesterase inhibitor (−11.39, −18.38 to −3.93), massage and touch therapy (−9.03, −12.28 to −5.88), multidisciplinary care (−1.98, −3.80 to −0.16), occupational therapy (−2.59, −4.70 to −0.40), exercise combined with social interaction and cognitive stimulation (−12.37, −19.01 to −5.36), and reminiscence therapy (−2.30, −3.68 to −0.93). Except for massage and touch therapy, cognitive stimulation combined with a cholinesterase inhibitor, and cognitive stimulation combined with exercise and social interaction, which were more efficacious than some drug interventions, no statistically significant difference was found in the comparative efficacy of drug and non-drug interventions for reducing symptoms of depression in people with dementia without a diagnosis of a major depressive disorder. Clinical and methodological heterogeneity precluded network meta-analysis of studies comparing the efficacy of interventions specifically for reducing symptoms of depression in people with dementia and a major depressive disorder (22 studies; 1829 patients). Conclusions In this systematic review, non-drug interventions were found to be more efficacious than drug interventions for reducing symptoms of depression in people with dementia without a major depressive disorder. Systematic review registration PROSPERO CRD42017050130.

Depression and Dementia in Older Adults: A Neuropsychological Review

“…The most important thing for us, as therapists, to do for (very) older patients with so-called psychogenic symptoms is to accept their symptoms in a supportive manner while conducting tests in small doses, minimizing the use of medications, and looking for ways to distract them from their symptoms in their daily lives. A recent systematic review also reported that nonpharmacological interventions are more effective than pharmacological interventions in reducing symptoms of depression in dementia patients without MDD [ 121 ]. The best thing to do is to encourage these older adults to immerse themselves in whatever interests them, and if they have outstanding abilities, it is best to help them exercise those abilities.…”

Managing neuropsychiatric symptoms in patients with dementia

“…Multidisciplinary care and interventions such as massage and touch therapy lead to clinically meaningful reductions in symptoms (ie, the threshold above which clinicians, patients, and researchers perceive a change on an outcome scale) of agitation and aggression, as per a systematic review (189 studies, 25 736 patients, 17.5% of studies conducted in a clinic/community setting) published in 2019 11. Another systematic review published in 2021 (256 studies, 28 483 patients, 41% of studies conducted in a clinic/community setting) found that multidisciplinary care, occupational therapy, and non-medication interventions (eg, animal therapy and exercise, fig 2) resulted in clinically meaningful reductions in symptoms of depression in people with dementia (without a major depressive disorder) 12. Medications alone were not more efficacious than usual care in both of these reviews 68.…”

“…Missing outcome data and a lack of participant blinding limit validity of findings (table 4). 1112 Studies included in these systematic reviews ranged from less than one week to two years in duration and were conducted across different care settings (eg, community, nursing home) in predominantly high income countries 1112. The comparative cost effectiveness of efficacious interventions identified in these systematic reviews is unknown.…”

The effect of interventions targeting gut microbiota on depressive symptoms: a systematic review and meta-analysis

“…They also assessed study quality with the Cochrane Risk of Bias 2.0 tool. 19 We used a hierarchy developed by an expert psy chiatrist a priori to select an outcome from each study for inclusion in metaanalysis 20 when the same mental health outcome was measured with more than 1 validated tool, whereby we prioritized observerrated tools above selfrated tools, commonly used tools over less commonly used tools, and tools measuring specific symptoms over those measuring mixed symptoms.…”