Original Study| Volume 21, ISSUE 6, P872-878.e1, June 2020

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Depression in People With Dementia and Caregiver Outcomes: Results From the European Right Time Place Care Study



      To investigate the cross-sectional associations between depression in people with dementia and both caregiver burden and quality of life in 8 European countries, and to test these associations compared with the presence of other neuropsychiatric symptoms.


      Cross-sectional study.

      Setting and Participants

      In total, 1223 dyads comprised of informal caregivers and people with dementia living in a community-dwelling setting, recruited from the Right Time Place Care study, a cohort survey from 8 European countries.


      To test the associations between depression (according to the Cornell Scale for Depression in Dementia) and informal caregiver burden (defined by the Zarit scale and hours of supervision in terms of Resource Utilization in Dementia), distress (defined by the Neuropsychiatric Inventory Questionnaire distress score), and quality of life (according to the visual analogue scale and 12-item General Health Questionnaire).


      Linear regressions showed an association between depression and main outcomes (Zarit scale: β 3.7; P = .001; hours of supervision: β 1.7; P = .004; Neuropsychiatric Inventory Questionnaire distress score: β 1.2; P = .002). A similar association was found concerning psychological and overall well-being (12-item General Health Questionnaire: β 1.8; P < .001; Euroqol Visual Analogue Scale: β −4.1; P = .003). Both associations remained significant despite the presence of other NPS and after adjusting for confounders.

      Conclusions and Implications

      Further studies are needed to assess whether providing tailored strategies for optimizing diagnosis and managing of depression in people with dementia might improve caregiver quality of life and reduce their burden in the community-dwelling setting.


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      1. World Alzheimer Report 2018. The State of the Art of Dementia Research: New frontiers. New Front 48 C.Patterson - Alzheimer's Disease International (ADI): London, UK, 2018

        • Feast A.
        • Moniz-Cook E.
        • Stoner C.
        • et al.
        A systematic review of the relationship between Behavioral and Psychological Symptoms (BPSD) and caregiver well-being.
        Int Psychogeriatr. 2016; 28: 1761-1774
        • Majer R.
        • Simon V.
        • Csiba L.
        • et al.
        Behavioural and psychological symptoms in neurocognitive disorders: Specific patterns in dementia subtypes.
        Open Med. 2019; 14: 307-316
        • Kwok Y.-T.
        • Chen C.-Y.
        • Chiu M.-J.
        • et al.
        Assessment of behavioral and psychological symptoms of dementia by family caregivers.
        Arch Gerontol Geriatr. 2011; 52: 60-65
        • Arthur P.B.
        • Gitlin L.N.
        • Kairalla J.A.
        • Mann W.C.
        Relationship between the number of behavioral symptoms in dementia and caregiver distress: What is the tipping point?.
        Int Psychogeriatr. 2018; 30: 1099-1107
        • Crellin N.
        • Charlesworth G.
        • Orrell M.
        Measuring family caregiver efficacy for managing behavioral and psychological symptoms in dementia: A psychometric evaluation.
        Int Psychogeriatr. 2014; 26: 93-103
        • Balieiro Jr., A.P.
        • Sobreira E.S.T.
        • Pena M.C.S.
        • et al.
        Caregiver distress associated with behavioral and psychological symptoms in mild Alzheimer's disease.
        Dement Neuropsychol. 2010; 4: 238-244
        • Kamiya M.
        • Sakurai T.
        • Ogama N.
        • et al.
        Factors associated with increased caregivers' burden in several cognitive stages of Alzheimer's disease: Caregivers' burden in Alzheimer's disease.
        Geriatr Gerontol Int. 2014; 14: 45-55
        • Mukherjee A.
        • Biswas A.
        • Roy A.
        • et al.
        Behavioural and psychological symptoms of dementia: Correlates and impact on caregiver distress.
        Dement Geriatr Cogn Disord Extra. 2017; 7: 354-365
        • Fauth E.B.
        • Zarit S.H.
        • Femia E.E.
        • et al.
        Behavioral and psychological symptoms of dementia and caregivers' stress appraisals: Intra-individual stability and change over short-term observations.
        Aging Ment Health. 2006; 10: 563-573
        • Koyama A.
        • Matsushita M.
        • Hashimoto M.
        • et al.
        Mental health among younger and older caregivers of dementia patients: Mental health of dementia caregivers.
        Psychogeriatrics. 2017; 17: 108-114
        • Puranen A.
        • Taipale H.
        • Koponen M.
        • et al.
        Incidence of antidepressant use in community-dwelling persons with and without Alzheimer's disease: 13-year follow-up.
        Int J Geriatr Psychiatry. 2017; 32: 94-101
        • Zhao Q.-F.
        • Tan L.
        • Wang H.-F.
        • et al.
        The prevalence of neuropsychiatric symptoms in Alzheimer's disease: Systematic review and meta-analysis.
        J Affect Disord. 2016; 190: 264-271
        • Ford A.H.
        • Almeida O.P.
        Management of depression in patients with dementia: Is pharmacological treatment justified?.
        Drugs Aging. 2017; 34: 89-95
        • Perna L.
        • Wahl H.W.
        • Weberpals J.
        • et al.
        Incident depression and mortality among people with different types of dementia: Results from a longitudinal cohort study.
        Soc Psychiatry Psychiatr Epidemiol. 2019; 54: 793-801
        • Hurt C.
        • Bhattacharyya S.
        • Burns A.
        • et al.
        Patient and caregiver perspectives of quality of life in dementia.
        Dement Geriatr Cogn Disord. 2008; 26: 138-146
        • Verbeek H.
        • Meyer G.
        • Leino-Kilpi H.
        • et al.
        A European study investigating patterns of transition from home care towards institutional dementia care: The protocol of a Right Time Place Care study.
        BMC Public Health. 2012; 12: 68
        • Molloy D.W.
        • Alemayehu E.
        • Roberts R.
        Reliability of a standardized mini-mental state examination compared with the traditional Mini-Mental State Examination.
        Am J Psychiatry. 1991; 148: 102-105
        • Zarit S.H.
        • Reever K.E.
        • Bach-Peterson J.
        Relatives of the impaired elderly: Correlates of feelings of burden.
        The Gerontologist. 1980; 20: 649-655
      2. RUD - Resource Utilization in Dementia.
        (Available at:)
        • Alexopoulos G.S.
        • Abrams R.C.
        • Young R.C.
        • Shamoian C.A.
        Cornell scale for depression in dementia.
        Biol Psychiatry. 1988; 23: 271-284
        • Katz S.
        • Ford A.B.
        • Moskowitz R.W.
        • et al.
        Studies of illness in the aged. The index of ADL: A standardized measure of biological and psychosocial function.
        JAMA. 1963; 185: 914-919
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Folstein M.F.
        • Folstein S.E.
        • McHugh P.R.
        “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician.
        J Psychiatr Res. 1975; 12: 189-198
        • Cummings J.L.
        • Mega M.
        • Gray K.
        • et al.
        The Neuropsychiatric Inventory: Comprehensive assessment of psychopathology in dementia.
        Neurology. 1994; 44: 2308-2314
        • Kaufer D.I.
        • Cummings J.L.
        • Ketchel P.
        • et al.
        Validation of the NPI-Q, a brief clinical form of the neuropsychiatric inventory.
        J Neuropsychiatry Clin Neurosci. 2000; 12: 233-239
        • Canevelli M.
        • Adali N.
        • Voisin T.
        • et al.
        Behavioral and psychological subsyndromes in Alzheimer's disease using the Neuropsychiatric Inventory.
        Int J Geriatr Psychiatry. 2013; 28: 795-803
        • Torrisi M.
        • De Cola M.C.
        • Marra A.
        • et al.
        Neuropsychiatric symptoms in dementia may predict caregiver burden: A Sicilian exploratory study: BPSD and caregiver burden.
        Psychogeriatrics. 2017; 17: 103-107
        • Cova I.
        • Travi N.
        • Maggiore L.
        • et al.
        What are the caregivers' needs on dementia care? An integrated qualitative and quantitative assessment.
        Neurol Sci. 2018; 39: 1085-1091
        • Bremer P.
        • Cabrera E.
        • Leino-Kilpi H.
        • et al.
        Informal dementia care: Consequences for caregivers' health and health care use in 8 European countries.
        Health Policy. 2015; 119: 1459-1471
        • Afram B.
        • Stephan A.
        • Verbeek H.
        • et al.
        Reasons for institutionalization of people with dementia: Informal caregiver reports from 8 European countries.
        J Am Med Dir Assoc. 2014; 15: 108-116
        • Feast A.
        • Orrell M.
        • Russell I.
        • et al.
        The contribution of caregiver psychosocial factors to distress associated with behavioural and psychological symptoms in dementia: Psychosocial model of BPSD-related distress.
        Int J Geriatr Psychiatry. 2017; 32: 76-85
        • Ornstein K.A.
        • Gaugler J.E.
        • Devanand D.P.
        • et al.
        Are there sensitive time periods for dementia caregivers? The occurrence of behavioral and psychological symptoms in the early stages of dementia.
        Int Psychogeriatr. 2013; 25: 1453-1462
        • Baharudin A.D.
        • Din N.C.
        • Subramaniam P.
        • Razali R.
        The associations between Behavioral-psychological Symptoms of Dementia (BPSD) and coping strategy, burden of care and personality style among low-income caregivers of patients with dementia.
        BMC Public Health. 2019; 19: 447
        • Fauth E.B.
        • Gibbons A.
        Which behavioral and psychological symptoms of dementia are the most problematic? Variability by prevalence, intensity, distress ratings, and associations with caregiver depressive symptoms: Variability in BPSD identified as most problematic.
        Int J Geriatr Psychiatry. 2014; 29: 263-271
        • Hughes L.D.
        • Murphy F.
        • Findlay D.J.
        Assessment and treatment of depression associated with dementia.
        Br J Hosp Med. 2019; 80: 151-156
        • Leonpacher A.K.
        • Peters M.E.
        • Drye L.T.
        • et al.
        Effects of citalopram on neuropsychiatric symptoms in Alzheimer's dementia: Evidence from the CitAD Study.
        Am J Psychiatry. 2016; 173: 473-480
        • Kok R.M.
        • Reynolds C.F.
        Management of depression in older adults: A review.
        JAMA. 2017; 317: 2114
        • Nelson J.C.
        • Devanand D.P.
        A systematic review and meta-analysis of placebo-controlled antidepressant studies in people with depression and dementia.
        J Am Geriatr Soc. 2011; 59: 577-585
        • Chi S.
        • Wang C.
        • Jiang T.
        • et al.
        The prevalence of depression in Alzheimer's disease: A systematic review and meta-analysis.
        Curr Alzheimer Res. 2015; 12: 189-198
        • Zauszniewski J.A.
        • Lekhak N.
        • Musil C.M.
        Caregiver reactions to dementia symptoms: Effects on coping repertoire and mental health.
        Issues Ment Health Nurs. 2018; 39: 382-387
        • Hsu T.-J.
        • Tsai H.-T.
        • Hwang A.-C.
        • et al.
        Predictors of nonpharmacological intervention effect on cognitive function and behavioral and psychological symptoms of older people with dementia: Nonpharmacological intervention for dementia.
        Geriatr Gerontol Int. 2017; 17: 28-35
        • Terayama H.
        • Sakurai H.
        • Namioka N.
        • et al.
        Caregivers' education decreases depression symptoms and burden in caregivers of patients with dementia: Caregiver depression and burden.
        Psychogeriatrics. 2018; 18: 327-333
        • Kales H.C.
        • Gitlin L.N.
        • Stanislawski B.
        • et al.
        WeCareAdvisorTM: The development of a caregiver-focused, web-based program to assess and manage behavioral and psychological symptoms of dementia.
        Alzheimer Dis Assoc Disord. 2017; 31: 263-270
        • Alvira M.C.
        • Risco E.
        • Cabrera E.
        • et al.
        The association between positive-negative reactions of informal caregivers of people with dementia and health outcomes in eight European countries: A cross-sectional study.
        J Adv Nurs. 2015; 71: 1417-1434