Depression or Dementia?
Is it depression or dementia? This question can pose challenges in nursing homes. “Clinically, late-life depression and dementia can be indistinguishable,” according to Burke et al. They say that neuropsychiatric symptoms affect 97% of patients with Alzheimer’s disease. Among the most common symptoms are apathy and depression.
As compared with non-Alzheimer’s patients who suffer depression, depressed individuals with Alzheimer’s are more likely to exhibit psychotic symptoms, psychomotor agitation, and fatigue, explain Burke and colleagues.
Depression and dementia can be related
Burke et al. report that there appears to be a correlation between depression and dementia. In the clinical setting, they note that mild cognitive impairment carries a depression incidence rate of 40%.
“Depression is also a predictor of progression from normal cognition to mild cognitive impairment and from mild cognitive impairment to dementia,” they state. In addition, “There is evidence that depression may be an early manifestation of Alzheimer’s disease.”
Overall, they say that late-life depression is “underdiagnosed and inadequately treated.” With this comes a drop in quality of living, along with increased morbidity and mortality.
NIMH criteria for depression in Alzheimer’s
Diminished ability to think or concentrate nearly every day is one of the DSM-5 diagnostic criteria for depression. However, when a patient presents with an Alzheimer’s diagnosis alongside diminished ability to think or concentrate, does this represent depression or not?
The National Institute of Mental Health tackled this question in 2001. They determined that diagnostic criteria for depression concurrent with Alzheimer’s disease needed to be adapted. An expert panel eliminated the criterion for diminished ability to think or concentrate, reduced the number of symptoms that need to be present for a diagnosis, and added new symptoms addressing withdrawal, social isolation, and irritability (Burke et al.).
By their criteria, when a patient already meets criteria for an Alzheimer’s diagnosis, three or more of the following symptoms within the same 2-week period and representing a change from previous functioning can assist with making a diagnosis of depression. (At least one of the first two is required for the diagnosis.)
- Clinically significant depressed mood
- Decreased positive affect or pleasure in response to social contacts and usual activities
- Social isolation or withdrawal
- Disruption in appetite
- Disruption in sleep
- Psychomotor changes
- Irritability
- Fatigue or loss of energy
- Feelings of worthlessness, hopeless, or excessive or inappropriate guilt
- Recurrent thoughts of death, suicidal ideation, plan, or attempt.
There are additional qualifiers used in the diagnostic model to rule out other psychological conditions.
Neurobehavioral assessment for cognitively impaired patients
Burke et al. note that patient-focused depression scales may be invalid for individuals with cognitive impairment, because symptoms may be under-reported by impaired patients. In addition, they note that most common assessment tools were validated in younger populations. They recommend incorporating caregiver input during assessment. The assessment process for nursing home residents is far from simple.
t’s worth noting that the clinical picture of depression among patients with cognitive impairment or Alzheimer’s is highly variable, according to Burke et al. They describe it as “a heterogeneous group of disorders requiring careful neuropsychiatric assessment and treatment planning”.
Learn more about the specialty of geropsychology and why you need a psychologist on your dementia care team to conduct comprehensive neurobehavioral assessment. We firmly believe that accurate diagnosis drives treatment. How may we support you? Get in touch any time.