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Depression in Patient with Dementia

by Esther Oh, M.D.

Introduction

This is a case of a patient with history of dementia who presented with agitation. This case demonstrates that depression in a patient with dementia may not present with typical symptoms of depression as seen in the general population. Treatments may include behavioral and caregiver interventions in addition to medication.

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Case Presentation

History of Present Illness
The patient is a 77 year old man with past medical history significant for dementia, hyperlipidemia, coronary artery disease (CAD), s/p coronary artery bypass graft (CABG) and aortic valve replacement  (AVR) who was referred to the Memory Clinic for agitation.

According to the patient’s family member, he started having memory problems in 2002, which worsened significantly after his CABG and AVR in 2004. At the time he presented to the clinic, he had functional deficits in the following instrumental activities of daily living (IADLs) – handling finances, driving, cooking and shopping.
The patient was noted to be easily agitated and irritable for sometime, and was referred to the Memory Clinic for exhibiting verbal and physical aggression towards his wife as well as others. The patient was recently seen by his primary care physician for this issue, and all of his laboratory exams were normal, and subsequent MRI of the brain was also unremarkable.

The patient noted good appetite and denied problems with sleeping or weight changes. He also denied any suicidal ideations and visual/auditory hallucinations. However, he stated that he was depressed because he was worried about his memory problems.

The patient’s Mini-Mental State Examination (MMSE) was 16/30, and Cornell Scale for Depression in Dementia was 8 for the patient and 14 for the wife. 

Assessment and Plan
The patient had few typical symptoms of depression, however had agitation and irritability noted by his wife in addition to depressed mood expressed by the patient. In this case, the patient may be minimizing or is unaware of his symptoms due to his dementia. The patient was started on 25mg PO qD of a Selective Serotonin Reuptake Inhibitor (SSRI) which was increased to 50mg PO qD after one week. The patient’s wife was also instructed on behavioral management of agitation and aggression, and was encouraged to contact the Alzheimer’s Association for caregiver support group.

Follow up
The patient and his wife returned four weeks later. The wife reported complete resolution of the symptoms, and the patient denied feelings of depression, stating “I am a happy man.” The patient’s wife also noted that she had contacted the Alzheimer’s Association, and joined a caregiver support group. She learned about different strategies to care for her husband to minimize his symptoms.

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Discussion

Epidemiology of Depression in Patients with Dementia
Depression in older adults is estimated to range from 7-36 % in the outpatient setting(1), and in patients with dementia, the numbers range from 15-50 %.(2) Depression in patients with dementia may go undetected due to the fact that the symptomology of depression in these patients manifest differently from cognitively normal patients.

Diagnosis of Depression in Patients with Dementia
Patients with Dementia May Have Different Clinical Manifestations of Depression
 
In a study comparing major depressive features between patients with Alzheimer’s disease (AD)* and cognitively normal older adults, several significant differences were noted in the study.  Patients with AD had significantly diminished ability to concentrate or indecisiveness, less disturbances in sleep, and less reports of feelings of worthlessness or excessive guilt.  However, patients with AD were noted to have higher rates of delusions and hallucinations. There was also a trend towards higher rates of psychomotor agitation/retardation and fatigue/loss of energy in more advanced AD patients.(3)
*AD is the most common cause of dementia in the older population.(4)

Screening Tools for Diagnosing Depression in Patients with Dementia
 
While a screening tool such as the Geriatric Depression Scale (GDS) is commonly used to screen for depression, there may be an underreporting on the part of the patients with dementia as they are unable to recall or are not aware of the depressive symptoms reported by the caregivers.(3) The reliability of GDS diminishes with MMSE below 15.(5)  Input from caregivers become more important as the patient’s cognitive status declines. Therefore, an assessment tool that incorporates caregiver input such as Cornell Scale for Depression in Dementia (CSDD)(6)  may be more appropriate in patients with dementia. CSDD scores above 12 requires treatment, and above 8 requires more close follow up and possibly treatment.(7)

Treatment of Depression in Patients with Dementia
Depression can be a contributing factor in functional decline in dementia, and treatment of depression may improve functional levels in these patients.(8,7)
 
Non-pharmacological Intervention
 
Non-pharmacological methods should be the first-line intervention in treatment of depression in patients with dementia. Interventions targeting the patient as well as the caregiver are important. These may range from arranging a day care for the patient to participate in activities to educating the caregivers on different care giving skills.(7)

Pharmacological Intervention
 
Once the non-pharmacological intervention has been instituted, and or if a patient suffers from severe depressive symptoms, pharmacological intervention is warranted. A SSRI is generally recommended due to the relatively benign side effect profile.(7) Recommended antidepressants and their doses are shown in the table below. 

Antidepressants should be titrated to improvement in the target symptoms. In addition to the classical symptoms of depression such as sadness, anhedonia, insomnia and anorexia, other symptoms such as irritability, anxiety, and agitation are also valid target symptoms for treatment. Medications should be started at a low dose, and titrated slowly, and 8-12 weeks may be needed for a full treatment response.(9,8)

ANTIDEPRESSANT MEDICATIONS FOR DEPRESSION IN AD

Drug

Initial
  Dose

Maximum
Dose

Comments

Fluoxetine

10 mg

20–40 mg

SSRIs in general: widely used due to favorable safety profile and effect on anxiety. Side effects include GI distress, anxiety, insomnia, medication interactions. FDA warning concerning emerging suicidality suggests careful monitoring in initial 10 days of treatment.

Fluoxetine has long half-life with weekly preparation available but prolonged side effects.

Sertraline

25 mg

150 mg

(see fluoxetine).

Paroxetine

10 mg

20–40 mg

(see fluoxetine) May be calming and helpful for sleep.

Citalopram

10 mg

20–40 mg

(see fluoxetine).

Escitalopram

5 mg

20 mg

(see fluoxetine) Enantiomer of citalopram.

Venlafaxine(long-acting)

37.5 mg

225 mg

Side effect of hypertension (3%). More stimulating than SSRIs.

Bupropion
(long-acting)

75 mg

450 mg

Side effect of seizures (at supra-therapeutic doses only). Dopaminergic effect may also be more stimulating than SSRIs.

Mirtazapine

7.5 mg

30 mg

Side effect of weight gain, sedation. Use at bedtime. Widely used as hypnotic.

Nortriptyline

10 mg

100 mg

Side effect of constipation, dry mouth. Best choice among tricyclic antidepressants due to favorable side effects profile.

Methylphenidate

5 mg in the morning

10 mg at breakfast and lunch

Side effects of insomnia, dyskinetic movements.  May be helpful for apathy and fatigue. Limited research base.

Duloxetine

20 mg
twice daily

40–60 mg
twice daily

Side effect of hypertension less common than venlafaxine, sexual side effects less common than SSRIs. May be helpful for pain and somatizing syndromes.

Rosenberg, P.B. and Lyketsos, C.B. 2006

I would like to thank Dr. Paul Rosenberg of the Division of Geriatric Psychiatry and Neuropsychiatry at the Johns Hopkins School of Medicine for his review of this educational module.

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References

  1. Koenig HG, Blazer DG. Epidemiology of geriatric affective disorders. Clin Geriatr Med. 1992;8:235-251.
     
  2. Olin JT, Katz IR, Meyers BS, Schneider LS, Lebowitz BD. Provisional diagnostic criteria for depression of alzheimer disease: Rationale and background. Am J Geriatr Psychiatry. 2002;10:129-141.
     
  3. Zubenko GS, Zubenko WN, McPherson S, et al. A collaborative study of the emergence and clinical features of the major depressive syndrome of Alzheimer's disease. Am J Psychiatry. 2003;160:857-866.
     
  4. Evans DA, Funkenstein HH, Albert MS, et al. Prevalence of Alzheimer's disease in a community population of older persons. higher than previously reported. JAMA. 1989;262:2551-2556.
     
  5. McGivney SA, Mulvihill M, Taylor B. Validating the GDS depression screen in the nursing home. J Am Geriatr Soc. 1994;42:490-492.
     
  6. Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. Cornell scale for depression in dementia. Biol Psychiatry. 1988;23:271-284.
     
  7. Lyketsos CG, Lee HB. Diagnosis and treatment of depression in Alzheimer's disease. A practical update for the clinician. Dement Geriatr Cogn Disord. 2004;17:55-64.
     
  8. Lyketsos CG, DelCampo L, Steinberg M, et al. Treating depression in alzheimer disease: Efficacy and safety of sertraline therapy, and the benefits of depression reduction: The DIADS. Arch Gen Psychiatry. 2003;60:737-746.
     
  9. Rosenberg PB, Lyketsos CB. Depression in alzheimer disease. In: Charney, D.S and Evans D., ed. The Physician's Guide to Depression and Bipolar Disorder. McGraw-Hill; 2006.

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