Download depression in dementia

OCTOBER 2010
DEPRESSION IN DEMENTIA
D
epression is very common among people with
dementia, especially in the early stages. Depressive
symptoms have been reported to occur in
approximately 40-50% of people with Alzheimer’s disease.
People in residential care appear to be particularly at risk of
depression.
Whilst depression is a mood disorder, it can adversely affect
cognitive function and result in poor memory, difficulty in
decision-making and difficulty in organising and initiating
activities.
Depression may exacerbate the symptoms of dementia. Residents with dementia and depression may have increased
disability in activities of daily living, worse quality of life
and higher mortality.
It is important to recognise when these two conditions coexist and to manage both conditions appropriately.
Signs and symptoms
Depression often presents with symptoms suggestive of
dementia, and depression may co-exist with dementia.
There are many symptoms common to both dementia and
depression:
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Confusion
Memory disturbance
Impaired ability to concentrate
Depression in a person with dementia may worsen their
symptoms of dementia making residents more confused,
anxious and withdrawn. Depression is frequently associated
with apathy in Alzheimer’s disease (AD). Depression can
accelerate cognitive decline in dementia.
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Depressed mood or decreased positive affect or pleasure
Social isolation or withdrawal
Disruption in appetite
Disruption in sleep
Psychomotor changes
Irritability
Fatigue or loss of energy
Feelings of worthlessness, hopelessness, or excessive or inappropriate guilt
Recurrent thoughts of death, suicidal ideation, plan or attempt
Mood changes may be underreported by the resident due to
poor awareness of their behavioural and emotional changes.
Marked urinary frequency or urgency, and bladder pain may
be signs of bladder cancer.
Assessment
The Cornell Scale for Depression in Dementia (CSDD)
specifically developed to assess signs and symptoms of
major depression in patients with dementia. It is based on
information provided by a caregiver and the patient.
Medication-related causes
Depression may also be due to medications (e.g.
corticosteroids, beta blockers, oral contraceptives, levodopa,
interferon or isotretinoin) and other conditions such as
hypothyroidism.
Treatment
Depression and dementia are different conditions that require
different treatment.
Cognitive behavioural therapy (CBT) and behavioural
interventions are proven treatments for depression.
It may also cause behavioural changes such as wandering,
social withdrawal and refusal to eat. Residents with
dementia who show physical or verbal aggression have a
higher prevalence of depression than those without such
behaviours.
Electroconvulsive therapy (ECT) is an effective treatment
for depression in dementia, leading to improvements in both
mood and cognition.
Diagnostic criteria for depression with dementia include
criteria for AD based on assessment with mini-mental state
examination (MMSE) together with three or more of the
following symptoms during the same 2-week period and
represent a change from previous functioning:
All antidepressant medications are approximately equal
in efficacy, although the response can vary considerably
between patients.
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Antidepressants
Antidepressants have different side effects and potential for
drug-drug interactions.
Depression in Dementia, continued
Different classes of antidepressants include:
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Tricyclic antidepressants (TCAs)
Tetracyclic antidepressant e.g. mianserin (Tolvon, Lumin)
Selective serotonin reuptake inhibitors (SSRIs)
Serotonin and noradrenaline reuptake inhibitors (SNRIs) e.g. duloxetine (Cymbalta), venlafaxine (Efexor-XR), desvenlafaxine (Pristiq)
Monoamine oxidase inhibitors (MAOIs) e.g. phenelzine (Nardil), tranylcypromine (Parnate)
Reversible inhibitors monoamine oxidase type-A (RIMA) e.g. moclobemide (Aurorix)
Noradrenaline reuptake inhibitor e.g. reboxetine (Edronax)
As always, if antidepressant drug treatment is ineffective it
should be ceased. An adequate duration of antidepressant
therapy at an adequate dose is necessary.
Selective serotonin reuptake inhibitors (SSRIs) are most
often used for treating depression in dementia. SSRIs are
effective in reducing depressive symptoms and improving
associated behavioural disturbances, including agitation,
irritability, and restlessness among patients with dementia.
Whilst SSRIs are better tolerated than TCAs, they may
induce agitation, anxiety, tremor and sleep problems.
SSRIs include:
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Citalopram (Cipramil, Celapram, Celica, Ciazil, Citalobell, Talam, Talohexal)
Escitalopram (Lexapro, Esipram, Esitalo, Lexam)
Fluoxetine (Lovan, Prozac, Zactin, Fluohexal, Auscap, Fluoxeball)
Fluvoxamine (Luvox, Faverin, Movox, Voxam)
Paroxetine (Aropax, Extine)
Sertraline (Zoloft, Concorz, Sertra, Setrona, Eleva, Xydep)
Medications to avoid
In general, tricyclic antidepressants should be avoided in
people with dementia, as the anticholinergic effects can
worsen cognitive impairment and cause confusion and
sedation.
As anticholinergic agents such as tricyclic antidepressants
can antagonise the therapeutic benefit of cholinesterase
inhibitors, they should be avoided with donepezil (Aricept),
galantamine (Reminyl) and rivastigmine (Exelon).
Tricyclic antidepressants include:
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Amitriptyline (Endep)
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Clomipramine (Anafranil, Placil)
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Dothiepin (Dothep, Prothiaden)
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Doxepin (Deptran, Sinequan)
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Imipramine (Tofranil, Tolerade)
© Manrex Pty Ltd (ABN: 63 074 388 088) t/as Webstercare - 2010
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Nortriptyline (Allegron)
Trimipramine (Surmontil)
Nortriptyline is less sedating and has less anticholinergic
effects than other TCAs.
The SSRI paroxetine (Aropax, Extine) also has significant
anticholinergic activity and should be avoided in residents
with dementia.
Depression and risk of dementia
Recent evidence suggests that depression can double the
risk of dementia.
Residents with major depression and diabetes have an
increased risk of development of dementia compared to
those with diabetes alone.
Summary
Comorbid depression is common in all types of dementia.
Depression is also a risk factor for dementia and cognitive
decline.
Depression and dementia share many of the same symptoms.
Signs of depression in people with dementia can include
poor sleep, poor appetite, lack of energy and feelings of
guilt. Tricyclic antidepressants should be avoided in people
with dementia.
References
Antidepressants for treating depression in dementia.
Cochrane Database of Systematic Reviews 2002, Issue 4.
Cornell scale for depression in dementia. Biol Psych 1988,
23:271-284.
Depressive symptoms and risk of dementia: The Framingham
Heart Study. Neurology 2010;75:35-41.
Comorbid depression is associated with an increased risk of
dementia diagnosis in patients with diabetes. J Gen Intern Med
2010;25(5):423-9.