Swank Center for Memory Care and Geriatric Consultation, ChristianaCare
Learn about the relationship between depression and dementia, and about potential treatment options for depression.
Owen’s wife and children brought him to the Memory Clinic. He shuffled slowly into the office, barely putting one foot ahead of the other. He slumped on the couch with a weary sigh. When I asked him what brought him to our clinic, he raised his eyes toward his attentive wife. “He’s not the same person, doctor,” she said. “He has been different every since our primary care physician told him last year that he has dementia. He used to light up when our grandchildren visited. Now he doesn’t even pet the dog, and he loved that dog. He has a big CD collection that he doesn’t listen to anymore. I don’t think he’s sleeping well, and he’s lost so much weight that his clothes don’t fit anymore. He said ‘my life sucks’ and that he’d like to take a pill and be done with it all. What can we do? Is it depression or dementia that’s taking him away from us?”*
*Owen is a fictitious composite of multiple patients, to illustrate the important issues without risking the privacy of any individual’s protected health information.
Among people with dementia, depression is a frequent additional problem and one that can greatly diminish quality of life for both patient and care partner. Depression is especially common in people with vascular dementia but also affects many with Alzheimer’s disease. Overall, one recent analysis estimated that one in six people with dementia suffers from major depressive disorder. Milder but significant symptoms are even more common. In nursing home residents with dementia, the rates are even higher.
Researchers and clinicians have been thinking for a long time about the relationship between depression and dementia. Sometimes, depressive symptoms are the first glimpse of the brain failure that will lead to dementia. Some researchers believe that depression increases inflammation and other chemical changes in the body, actually increasing the risk of later dementia. Everyone agrees that depression and dementia together create more suffering and complications than either condition alone.
When depression accompanies dementia, identifying and treating it can potentially make life better for patient and care partner. However, finding depression is not always easy. Other conditions create symptoms that look like depression, misleading family and clinicians. Medical problems like low thyroid, some cancers, or sleep apnea sometimes create depression-like symptoms that take attention away from a medical problem that needs its own treatment. One recent study, too, pointed out the importance of attending to manageable factors in the patient’s living conditions. For example, physical pain and social isolation are important contributors to depression in people who are cognitively impaired, and they can be addressed.
A common symptom of dementia is apathy, the loss of initiative and motivation. Apathy is even more common than depression in people with dementia, but it doesn’t respond the same way to antidepressant treatment. In fact, some of the antidepressants can increase apathy, but a helpful clinician might not consider that possibility in a person who is withdrawn and fatigued. Apathy is not necessarily linked with sadness or suicidal feelings, so Owen’s comment about ending his life suggests that depression rather than apathy may be important in his case.
A further obstacle to recognizing depression in a person with dementia occurs when diminished insight interferes with a person’s ability to recognize or describe their emotions. A person with dementia and depression may feel desperate and yet be unable to express sadness in words. Delusional fears, agitation or withdrawal, or aggressive or suicidal behavior may be the most noticeable signs of depression in that person.
There is much controversy about how best to treat depression in a person with dementia. The cognitive-enhancing medications (cholinesterase inhibitors and memantine) don’t seem to have significant value in treating depression.
Among the many studies of antidepressant medications used for this purpose, the majority have not shown medication to be better than placebo.
Many experienced clinicians and some of the research, though, claim that an antidepressant trial is worth undertaking when depressive symptoms are typical of major depressive disorder. Some antidepressants, too, reduce agitation that may represent disguised depression.
The important point is to watch for adverse effects or lack of response and stop the medication if that is clinically appropriate. Antidepressant doses should start low and be increased cautiously, but it’s important not to under-dose, which can interfere with effectiveness. If the medication seems to help, it may be appropriate to try tapering and to stop the antidepressant once depressive symptoms have been absent for six months or more. Periodic re-evaluation of the need for an antidepressant is helpful in reducing unnecessary pharmacotherapy. Discontinuing an antidepressant should be gradual when that’s possible. When done too quickly, discontinuation symptoms can be unpleasant. Some patients do best with ongoing maintenance therapy to prevent the return of depressive symptoms. The pros and cons of continuing therapy need to be considered for each individual.
Families often ask about psychotherapy for depression. Psychotherapy’s value can be difficult to assess when advancing dementia interferes with understanding and memory.
Insight-oriented psychotherapy may be especially useful during the earlier stages of cognitive impairment.
Later on, a person with dementia may find it more comforting to participate in reminiscence therapy, behavioral activation, music therapy, or other non-medication approaches that emphasize group interaction and relaxation.
A final consideration regarding dementia and depression concerns care partners of people with dementia. Caregiving is a stressful responsibility and increases the risk of depression for the caregiver. One recent report found that more than two of every three caregivers scored high on a test of depression. The risk for depression was greater among caregivers who were older, or had attained a lower educational level, or had less support from other family members.
Depression risk was also increased when the severity of dementia was greater in the care recipient. A healthier care partner will enjoy a better quality of life and will also have more to offer the care recipient.
Owen’s evaluation suggested that depression was indeed present along with dementia, but found no treatable medical cause. Owen had been a music lover, and his family was encouraged to involve a music therapist in his care. Also, they were told of the value of physical activity and social involvement in reducing feelings of isolation and despair. An antidepressant trial, fortunately, was well-tolerated. The medication seemed to improve Owen’s appetite and sleep. During the follow up visit, his family reported significant improvement in his outlook and no more nihilistic or suicidal comments. After depressive symptoms were absent for six months, Owen’s antidepressant was tapered and stopped. Two years later, there had been no recurrence.
Asmer MS, Kirkham J, Newton H, et al. Meta-analysis of the prevalence of major depressive disorder among older adults with dementia. J Clin Psychiatry 2018;79. Pii: 17r11772. doi: 10.4088/JCP.17r11772.
Kubo Y, Hayashi H, Kozawa S, et al. Relevant factors of depression in dementia modifiable by non- pharmacotherapy: a systematic review. Psychogeriatrics 2018 Sep 23. doi: 10.1111/psyg.12371.
Bassiony MM, Warren A, Rosenblatt A, et al. The relationship between delusions and depression in Alzheimer's disease. Int J Geriatr Psychiatry. 2002 Jun;17(6):549-56.
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Omranifard V, Haghighizadeh E, Akouchekian S. Depression in main caregivers of dementia patients prevalence and predictors. Adv Biomed Res 2018;21;7:34. doi: 10.4103/2277-9175.225.
James Ellison, MD received his medical degree from UCSF in 1978 and trained in psychiatry at the Massachusetts General Hospital (1979-1982).
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