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Depression Vs. Dementia: How Do We Assess?

Depression Vs. Dementia: How Do We Assess?

Depression vs. : How Do We Assess?

Depressive disorder and dementia are common in older people, and may occur separately or together. Diagnosis is often challenging because of the frequency of symptoms which are common to both disorders. Unfortunately, underdiagnosis of results in missed opportunities to improve functioning, decreased and possibly even increased mortality. Yet, overdiagnosis of depression may result in unnecessary adverse effects of psychotropic . This article suggests approaches to .

By Lilian Thorpe MD, PhD, FRCP

ementia increases with age, with These include dysthymic disorder, least two contradictory directions of Dan overall prevalence in Canada depressive epi sodes of a bipolar dis- potentially causal influence. One of 8% in those 65 years and older, order, mood disorders secondary to a hypothesis suggests that depression 2.4% in those aged 65 to 74 years, medical disorder (such as hypothy- leads to dementia, and another that 11.1% in those aged 75 to 84 years, roidism), mood disorders secondary suggests that dementia itself leads and 34.5% in those aged 85 years and to a substance, adjustment disorders to depression. older.1 Alzheimer’s disease (AD) is and bereavement. Depressive disor- The depression-to-dementia dir ec - to be the most common type der is commonly seen in all stages of tion is supported by evidence that of dementia in all age groups. How - adult life and, while its prevalence is depressive disorder is a risk factor for ever, younger age groups are more slightly lower in the elderly,4 its developing dementia in later life6 and, likely than older age groups to be sequelae are probably greater in more consistent with this, the best-studied diagnosed with other , such frail people, exerting a more deleteri- people with a biological predisposition as and vas- ous effect on functional abilities and to develop AD (those with Down cular dementia.2 even increasing the length of stay for ) are thought to have a high Major depressive disorder is also hospitalizations related to primary risk of suffering from depression.7 The common, but is only one of a number medical conditions.5 Depressive dis- association between depression and of disorders listed in the Diagnostic order in seniors can occur as part of a later development of dementia is still and Statistical Manual of Mental lifelong recurrent disorder, or it can not completely understood. One possi- Disorders (DSM-IV)3 with prominent present for the first time in . It bility is that depression is an early, pro- depressive symptoms (Table 1).3 is frequently concurrent with other dromal phase of dementia,8 and is medical and mental disorders, includ- caused by the same pathophysiologic ing various dementias. initiators that result in dementia. There Lilian Thorpe MD, PhD, FRCP is also evidence that depression is Clinical Professor of , Relationships Between associated with damage to brain loca- and Professor of Community Health and Epidemiology, Dementia and Depression tions integral to cognitive processes, University of Saskatchewan Dementia and depression have a such as the , possibly Saskatoon, Saskatchewan complicated relationship, with at by decreasing neurogenesis.9 This

The Canadian Review of Alzheimer’s Disease and Other Dementias • 17

those with dementia,17,18 although a Table 1 recent Danish study suggests that this DSM-IV Mental Disorders with Prominent Depressive may now have changed, at least in Symptoms3 Denmark.19 Underdiagnosis of dep - • Major depressive disorder ression in demented seniors is clearly • Dysthymic disorder undesirable, as depressive disorders • (depressive episode) in the demented elderly have been • Mood disorders secondary to a general medical condition associated with additional burden, as • Mood disorders secondary to a substance (such as a ) described above. Undertreat ment with may also result • with depressed mood in over treatment of depression-asso- • Bereavement ciated behaviors with benzodi- azepines and possibly neuroleptics. process may lower the threshold for depression in dementia by using four Adverse effects of later observable cognitive loss, even- different scales in the same popula- and neuroleptics are well recognized tually increasing age-adjusted demen- tion, and found that between 27.5% and include increased falls, decreased tia rates. Behaviors associated with and 53.4% of people with mild AD alertness, extrapyramidal side effects, depression, such as heavy alcohol and between 36.3% and 68.4% with decreased mobility, decreased func- uses and vascular risk factors like moderate to severe AD were found to tioning and increased mortality. cigarette smoking,10 may also inde- rate positive for depression. Studies Efforts have been made to increase pendently increase later cognitive comparing differences in the preva- the recognition of depression in those loss, while medications prescribed to lence of carefully diagnosed depres- with dementia, and widely used treat depression, especially those sive disorders between matched instruments such as the Minimum with strong effects, demented and non-demented popula- Data Set20 include quality indicators could conceivably have adverse cog- tions are not frequent, but suggest that to alert administrators of patients with nitive effects, although this effect is motivational deficits in dementia may likely depression who are not being likely more transient. be the greatest difference between treated with antidepressants. Review The dementia-to-depression dir- these groups, rather than typical of these quality indicators may pre- ection in the potentially causal rela- DSM-IV major depressive disorder.13 cipitate discussion with attending tionship between the two disorders is However, regardless of the exact physicians, who have the opportunity supported by findings that people prevalence of formally diagnosed to institute appropriate treatment. with dementia appear to have a high- depressive disorder in dementia, it Unfortunately, this process may er prevalence of depression.11 does seem that depressive also result in an overdiagnosis of However, prevalence rates vary wide- are very common in those with depressive disorder due to the high ly depending on the study population dementia, and that this prevalence of behavioral symptoms (psychiatric outpatients, Alzheimer causes increased deficits in function- in dementia such as and reac- registries, old-age homes), instru- ing, increased problematic behav- tive mood symptoms, which overlap ments used, and diagnostic defini- ior,11 increased nursing-home place- with those seen in major depressive tions. Most problematically, the term ment,14 increased ,15 disorder. Treatment with antidepres- depression is used to denote different and increased mortality.16 sants is increasingly also known to be clinical concepts, which are not associated with adverse effects, most always equivalent to a diagnosis of Under- and Overdiagnosis of problematically in older, frail popula- DSM-IV major depressive disorder. Depression in Dementia tions. Anticholinergic effects of the Muller-Thomsen et al12 illustrated Depressive disorder has long been tricyclic antidepressants may cause large variability in the diagnosis of thought to be underdiagnosed in , constipation, urinary reten-

18 • The Canadian Review of Alzheimer’s Disease and Other Dementias Depression vs. Dementia

tion, and visual-accommodation prob- lems. Postural hypotension may cause Table 2 falls, and cardiac effects are particu- DSM-IV Symptoms of a Major Depressive Episode larly dangerous in overdose. Newer • Depressed mood medications, such as selective sero- • Markedly diminished interest or pleasure tonin reuptake inhibitors (SSRIs) and • Significant weight change venlafaxine, were initially felt to be • Changes in sleep patterns much safer, but have been increasing- • or retardation ly associated with different, rather • Fatigue or loss of energy than fewer, adverse effects. • Feelings of worthlessness, excessive or inappropriate guilt Gastrointestinal side effects and sleep disturbances appear to be more • Diminished ability to think or concentrate common with this group of medica- • Recurrent of death, suicidal ideation or suicidal actions tions. Recent research has suggested that SSRIs are no less likely than tri- ing behavior, decreased initiative le,26 the Geriatric Depression Scale,27 cyclic antidepressants to cause falls.21 and interest (apathy), psychomotor the Hamilton Depression Rating They are also associated with a higher agitation, and poor concentration (in Scale,28 the Montgomery and Asberg prevalence of hyponatremia,22 and advanced dementia) are common in Depression Rating Scale29 and the most recently research has suggested dementia without depression. Reac - Zung scale.30 Although these scales they increase fragility fractures.23 tive symptoms such as and vary considerably in how much they Finally, SSRIs have been associated tearfulness are also seen frequently are affected by impairments in lan- with increased apathy,24 even in those in dementia without depression, and guage, awareness and comprehen- who have been appropriately diag- may be related to retained aware- sion, none is useful in the later stages nosed with depression and have ness of deficits in the early stages of of dementia. Of greater usefulness in responded to this medication. dementia, poor coping skills and patients with advanced dementia are disorientation in the later stages, or the Dementia Mood Assessment Challenges in the Diagnosis to the mood lability accompanying Scale31 and the Cornell Scale for of Depression in Dementia vascular brain disease (which com- Depression in Dementia.32 Diagnosing depressive disorder in monly overlaps with AD). However, the gold-standard differ- the context of dementia is often dif- Much less common in dementia ential diagnosis of depression in ficult due to overlapping symptoms without depression are consistent dementia is a careful clinical assess- between depression and dementia, sadness, marked morning mood ment, which includes obtaining infor- communication problems and lack of worsening, feelings of worthlessness mation directly from the patient and insight. Behavioral and psychologi- or excessive or inappropriate guilt, from collateral sources, ideally those cal symptoms of dementia (BPSD) recurrent thoughts of death, suicidal with good knowledge of the person. are integral parts of the clinical pres- ideation or suicidal actions. This assessment should include: entation of dementia, although this • Careful symptom history is often thought of as a disorder of Approach to Clinical including: progressive cognitive decline. Diagnosis - detailed description; BPSD includes many of those A variety of instruments have been - time course and progression symptoms also seen characteristi- developed to screen for depression in of symptoms; as well as cally in DSM-IV depressive disor- the cognitively intact population. - association with other ders. Of the core symptoms of These include the Beck Depression confounding factors such as depressive disorder, listed in Table 2, Inventory,25 the Centre for Epide - environmental stressors which sleep disturbances, changes in eat- miological Studies-Depression Sca - include:

The Canadian Review of Alzheimer’s Disease and Other Dementias • 19 Vascular Dementia

Table 3 Typical Presentations of Mood Symptoms in Dementia and Depression

Symptom Dementia Depression General response to Frequent lack of concern or denial about symptoms. Amplification of and excessive cognitive and functional preoccupation with deficits. decline

Mood Normal most of the time. Unhappiness is reactive Subacute (weeks) onset of pervasively to circumstances and fluctuates. Labile, especially sad mood, most of the day and nearly with vascular dementia. Mood often brightens every day. Doesn’t brighten much with with stimulation and support. stimulation.

Interest, initiative Gradual loss of interest and initiative (apathy) over a Subacute loss of interest and pleasure longer period of time (years rather than weeks). Not over a few weeks, frequently accompanied by statements of sadness, tearfulness, accompanied by sad mood and , or other distress. Still enjoys activities in a structured and occasionally statements of guilt, environment. hopelessness and self-harm.

Eating behavior and Gradual loss of weight (over months to years) which Subacute changes (weeks) in appetite weight is common in dementia. Large increases in weight leading to increase or decrease may be secondary to decreased activity, medications, in weight. and hyperorality in patients with frontal behavioral presentations (more common in frontotemporal dementia like Pick’s Disease).

Sleep Gradual disruption of the sleep-wake cycle (over Subacute changes in sleep over a few months to years) due to brain changes of dementia, weeks (increase or decrease). resulting in frequent night-time wakening and daytime sleeping.

Psychomotor agitation Gradual (months to years) increase in agitation, Subacute (weeks) onset, often worse generally worse during the latter part of the day in the morning, may be present (). Patient much worse in unfamiliar persistently throughout the day. settings (catastrophic reaction), and often seeking Generally accompanied by other people or places from earlier life experiences. depressive symptoms such as nihilistic statements or excessive guilt.

Psychomotor retardation Seen infrequently in mild to moderate dementia, Subacute onset of psychomotor but occasionally in very advanced dementia, and retardation (over weeks) in severe may be mimicked by Parkinson’s dementia (facial depression. masking, slow motor functioning) or advanced Pick’s Disease.

Energy Generally a normal energy level, but reduced Subacute decrease in energy and activity due to poor initiation related to decreased increased complaints of fatigue. executive functioning.

Guilt or worthlessness Uncommon, although transient statements of Common in severe depression, usually worthlessness might be seen in times of stress in accompanied with low mood as well those with preserved awareness of their own decline. as changes in appetite and sleep.

Concentration and Concentration is normal in early dementia, but Subacute loss of concentration and thinking impaired in late dementia. Thinking ability declines sustained focus. Often indecisive and throughout the course of dementia. concerned about making mistakes.

Suicidal thoughts Uncommon. Common. and actions

20 • The Canadian Review of Alzheimer’s Disease and Other Dementias Depression vs. Dementia

- ; consistently low mood and affect thy without associated sadness, cry- - poor nutritional status; that does not respond to ing, or changes in sleep or appetite - other medical stimulation; hopelessness, are unlikely to represent a depressive conditions; and expressions of guilt; feelings of disorder, whereas consistently sad - recent changes in worthlessness; and thoughts of mood or affect, not brightening dur- medications. self-harm. ing interpersonal contact and associ- • Particular should be • Laboratory investigations, such ated with subacute changes in sleep paid to depressive symptoms as hematology, thyroid function, and appetite are much more likely to which are less common in , , and represent depressive disorder that dementia alone such as: levels of medications, requires medical treatment. Table 3 - hopelessness; known to have a propensity to summarizes mood symptoms seen in - expressions of guilt; cause mood symptoms. depression and dementia, with a brief - feelings of worthlessness; and In addition to the above, neuro- discussion about their more typical - thoughts of self-harm. imaging might be performed to presentation in each disorder. • Frontal symptoms, such as explore the potential contribution of , and vascular pathology to mood lability Conclusion and Treatment decreased initiative, suggest and apathy, and to rule out other neu- Issues dementias with a strong frontal rologic problems such as normal- Sometimes it is very difficult to make component rather than depression. pressure . a firm diagnosis of depression in the • Information about family After this assessment, the clini- context of dementia, especially when history of mood disorders, cian has to weigh the information the dementia is very advanced. The previous personal history of obtained, taking into account the clinician will occasionally choose to depression and previous response likelihood that the accumulated instigate treatment regardless of to therapy for depression. information represents depression diagnostic certainty, weighing the • Direct interview of the person, rather than dementia alone. For possible benefits versus potential paying particular attention to: example, isolated symptoms of apa- adverse outcomes of treatment.

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