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10/8/2012
Dementia with Depression
A Diagnostic Challenge
L i A
Louis
A. C
Cancellaro,
ll
PHD
PHD, MD
Professor Emeritus
Interim Chair
October 12, 2012
Epidemiology
y Inexact diagnosis compromises research
y Major depressive disorder (MDD) either precedes
or co-exists with Alzheimer’s Disease (AD) occurs
more frequently than can be explained by chance
alone
y Prevalence rates:
-MDD in non-demented patients>60yo =0.6-8%
-MDD in AD (age/sex matched)=15-30%
Epidemiology
y ≤ 60% of non-demented elderly patients
with severe depression are later
diagnosed with AD (@ 3 yr. follow-up)
y Elderly patients with MDD + mild
cognitive decline are twice as likely to
develop AD than those without mild
cognitive decline, who had no greater
incidence of AD (@12 yr. follow-up)
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Etiology of Depression in AD
y Psychological
• Grief over loss of cognitive function
y Biological
• Analogous to stroke, especially dominant
hemisphere, where MDD is prevalent and
is responsive to anti-depressants
• AD has associated deterioration of locus
ceruleus, which is purportedly disrupted in
MDD, as well
Diagnosis
y Diagnosing depression in elderly
• Inexact
• Part of a continuum
• Sadness ↔ MDD ↔ Psychotic Depression
• Frequently presents with somatic symptoms as
opposed to classical DSM IV criteria
Diagnosis
y Diagnosing depression in elderly
• Use family + patient for history
• Report >2 weeks history of (one or more):
• Loss of energy, loss of interests
• Increase
I
in
i somatic
ti symptoms
t
w/o
/ adequate
d
t
physical explanation
• Behavioral and/or personality change
• Suicidal tendencies
• Delusions
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Diagnosis
y Diagnosing depression in elderly
• No precise diagnostic tests
• Biochemical
• Radiological
• Psychological
™Hamilton Depression Rating Scale
™DSM-IV
y Experienced clinicians are the most help
Diagnosis
y Diagnosing AD in elderly with MDD
• History of cognitive decline beyond just loss of
concentrating ability
• Patient may, or may not, complain of memory loss
• Cognitive psychological tests
• Mini-mental status
• Full battery
Diagnosis
y Diagnosing depression and AD in elderly
y Even more inexact, especially if signs of AD not
previously recognized
y MDD in elderly frequently presents with
personality change and/or somatic symptoms
•
•
•
•
•
Behavioral change
Loss of concentrating ability; poor judgment
Vague physical symptoms
Loss of energy
“Nerves”
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Diagnosis
y Depression + AD in elderly
• Difficult to make a dual diagnosis
• Serious risks associated with a missed diagnosis
• Thus, the clinician must consider the
coexistence of both conditions if one is present
present,
until proven otherwise
Epidemiology
y Suicide risk:
y For all patients 65 years of age vs <65:
• Rate =50% higher
• Lethality =1 out of 2 attempts vs1 out of 8
Diagnosis
y Depression in elderly with AD
y Use family + patient for history
y Report 2 weeks history of (one or more):
¾Loss of energy, loss of interests
¾Increase in somatic symptoms w/o
adequate physical explanation
¾Behavioral and/or personality
change
¾Suicidal tendencies
¾Delusions
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Dementia and Depression: Distinguishing
Features
Feature
Dementia
Onset
Unclear, insidious
Progression
Patient insight
Affect
Test Performance
Depression
Clear, recent, often a
major psychotic event
Uneven, often no
progression
Often unaware of deficits, Nearly always aware of
not distressed
deficits and quite
distressed
Bland, some lability
Marked disturbance
Poor cooperation and
Good cooperation and
effort, stable achievement, effort, variable
achievement, considerable
little test anxiety, “near
anxiety, “don’t know”
miss” responses
responses
Relatively steady decline
Short-term memory
Often impaired
Sometimes impaired
Long-term memory
Unimpaired early in
disease
Often inexplicably
impaired
Differential Diagnosis
y Endocrine
y Thyroid disease
y Diabetes Mellitus
y Cushing’s
y Addison
Addison’s
s
y Hyperparathyroidism
y Cardiovascular and pulmonary disease
y MI
y Congestive heart failure
y COPD
Differential Diagnosis
y Endocrine
y Cardiovascular and pulmonary disease
y Anemia
•
B12
y Kidney and liver disease
y
Hepatitis C
y Infections
y AIDS, TB, hepatitis, chronic fatigue syndrome, other chronic
infections
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Differential Diagnosis
y Endocrine
y Cardiovascular and pulmonary disease
y Anemia
y Kidney and liver disease
y Infections
y Neurological disease
y CVA, low pressure hydrocephalus, Parkinson’s,
subdural hematoma, sleep apnea, brain tumor, seizure
disorder
Differential Diagnosis
y Medication side effects and interactions
y Psychotropics
y Benzodiazepines
y Anti-psychotics
y Anti-convulsants
Anti convulsants
y Anti-depressants
y Sleeping agents
y Pulmonary and cardiac drugs
y Steroids
Differential Diagnosis
y Medication side effects and interactions
y Occult malignancy
y Lymphomas, leukemias, multiple myeloma
y Retro-peritoneal tumors
y Collagen vascular disease
y SLE, polymyalgia rheumatica, rheumatoid arthritis,
scleroderma, fibromyalgia
y Medications used in treatment
y Alcoholism
y Other psychiatric disorders
y Anxiety disorders
y Mania
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Evaluation and Management
Suspecting MDD either preceding or coexisting
with AD
y History (from patient and family)
y Chief Complaint
y
y
y
y
“Depressed” (less common)
“Nerves”
“Memory loss”
Somatic symptoms (↓energy, GI symptoms,
weakness)
Evaluation and Management
y History
y Chief Complaint
y Course of illness (one or more):
y 2 weeks
y ↓interest in daily activities
y ↓cognitive ability
y Personality change with impulsiveness
y Suicidal tendencies
Evaluation and Management
y History
y Assessment
• Lack of medical condition sufficient to explain signs
•
•
•
•
•
•
and symptoms
Patient more detached than usual
Meets most of DSM-IV criteria for MDD↓Performance
↓
on
cognitive tests
If AD present, caregivers report ↑frustration, ↑
hopelessness in themselves
Suicide risk factors reviewed with patient and family
Domestic violence risk factors reviewed
Review differential diagnosis, especially
medication side effects and interactions
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Evaluation and Management
y History
y Assessment
y Treatment: MDD in elderly patients with AD
• Medications
• Anti-depressants →
• ≤85% improvement in mood if MDD present
• Plus occasional improvement in cognition
• No improvement in mood or cognition if MDD is not present
Evaluation and Management
y History
y Assessment
y Treatment: MDD in elderly patients with AD
Medications:
• Anti-depressants:
A ti d
t low
l
d
doses, iincrease slowly
l l
• SSRI’s (1/4-1/2 normal starting dose)
• Fluoxetine (Prozac®)
• Sertraline (Zoloft®)
• Paroxetine (Paxil®)
•
•
•
SSRI’s + donepezil (Aricept ®) = safe
SSRI’s + other meds may alter metabolism
TCA’s not well tolerated
Evaluation and Management
y History
y Assessment
y Treatment: MDD in elderly patients with AD
Medications continued
• Anti-psychotics →
• ↓ agitation and violent risk
•
•
•
•
↓ delusions
Risperdone (Risperdal®) 0.25-1.0 mg/d
Haloperidol (Haldol®) 0.5-2.0 mg/d
Olanzapine (Zyprexa®) 2.5-10 mg/d
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Evaluation and Management
y History
y Assessment
y Treatment: MDD in elderly patients with AD
Medications
• Anti-depressants
• Anti-psychotics
• Anti-convulsants
• Minor tranquilizers →
• ↓ anxiety
• ↑ sedation
• ↓ cognition
Evaluation and Management
y History
y Assessment
y Treatment: MDD in elderly patients with AD
™Medications
™Psychotherapy (slow, repetitive process)
• Supportive
• Behavior (statistically significant improvement)
• Family (especially with caregivers)
Evaluation and Management
y History
y Assessment
y Treatment: MDD in elderly patients with AD
™Medications
™Psychotherapy
™Management of suicidal behavior
™ Frequent assessment
™ ECT may be required
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Summary
y MDD frequently precedes or co-exists with AD
y Diagnosis of MDD in elderly is inexact
y If MDD + AD is suspected, effective treatment
of the MDD can not only improve the mood and
behavior of the patient, but also improve
condition
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