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Dementia with Depression
A Diagnostic Challenge
Louis A. Cancellaro, PHD, MD
Professor Emeritus
Interim Chair
March 26, 2012
Epidemiology
Inexact diagnosis compromises research
Major depressive disorder (MDD) either precedes
or co-exists with Alzheimer’s Disease (AD) occurs
more frequently than can be explained by chance
alone
Prevalence rates:
-MDD in non-demented patients>60yo =0.6-8%
-MDD in AD (age/sex matched)=15-30%
Epidemiology
≤ 60% of non-demented elderly patients
with severe depression are later
diagnosed with AD (@ 3 yr. follow-up)
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)
Etiology of Depression in AD
Psychological
• Grief over loss of cognitive function
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
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
Diagnosing depression in elderly
• Use family + patient for history
• Report >2 weeks history of (one or more):
•
Loss of energy, loss of interests
•
Increase in somatic symptoms w/o adequate
physical explanation
•
Behavioral and/or personality change
•
Suicidal tendencies
•
Delusions
Diagnosis
Diagnosing depression in elderly
• No precise diagnostic tests
• Biochemical
• Radiological
• Psychological
Hamilton Depression Rating Scale
DSM-IV
Experienced clinicians are the most help
Diagnosis
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
Diagnosing depression and AD in elderly
Even more inexact, especially if signs of AD not
previously recognized
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”
Diagnosis
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,
until proven otherwise
Epidemiology
Suicide risk:
For all patients 65 years of age vs <65:
• Rate =50% higher
• Lethality =1 out of 2 attempts vs1 out of 8
Diagnosis
Depression in elderly with AD
Use family + patient for history
Report 2 weeks history of (one or more):
Loss of energy, loss of interests
Increase in somatic symptoms w/o
adequate physical explanation
Behavioral and/or personality
change
Suicidal tendencies
Delusions
Dementia and Depression: Distinguishing
Features
Feature
Dementia
Onset
Unclear, insidious
Progression
Patient insight
Affect
Test Performance
Depression
Clear, recent, often a
major psychotic event
Relatively steady decline
Uneven, often no
progression
Often unaware of deficits, Nearly always aware of
not distressed
deficits and quite
distressed
Bland, some lability
Marked disturbance
Good cooperation and
Poor cooperation and
effort, stable achievement, effort, variable
little test anxiety, “near
achievement, considerable
miss” responses
anxiety, “don’t know”
responses
Short-term memory
Often impaired
Sometimes impaired
Long-term memory
Unimpaired early in
disease
Often inexplicably
impaired
Differential Diagnosis
Endocrine
Thyroid disease
Diabetes Mellitus
Cushing’s
Addison’s
Hyperparathyroidism
Cardiovascular and pulmonary disease
MI
Congestive heart failure
COPD
Differential Diagnosis
Endocrine
Cardiovascular and pulmonary disease
Anemia
•
B12
Kidney and liver disease
Hepatitis C
Infections
AIDS, TB, hepatitis, chronic fatigue syndrome, other chronic
infections
Differential Diagnosis
Endocrine
Cardiovascular and pulmonary disease
Anemia
Kidney and liver disease
Infections
Neurological disease
CVA, low pressure hydrocephalus, Parkinson’s,
subdural hematoma, sleep apnea, brain tumor, seizure
disorder
Differential Diagnosis
Medication side effects and interactions
Psychotropics
Benzodiazepines
Anti-psychotics
Anti-convulsants
Anti-depressants
Sleeping agents
Pulmonary and cardiac drugs
Steroids
Differential Diagnosis
Medication side effects and interactions
Occult malignancy
Lymphomas, leukemias, multiple myeloma
Retro-peritoneal tumors
Collagen vascular disease
SLE, polymyalgia rheumatica, rheumatoid arthritis,
scleroderma, fibromyalgia
Medications used in treatment
Alcoholism
Other psychiatric disorders
Anxiety disorders
Mania
Evaluation and Management
Suspecting MDD either preceding or coexisting
with AD
History (from patient and family)
Chief Complaint
“Depressed” (less common)
“Nerves”
“Memory loss”
Somatic symptoms (↓energy, GI symptoms,
weakness)
Evaluation and Management
History
Chief Complaint
Course of illness (one or more):
2 weeks
↓interest in daily activities
↓cognitive ability
Personality change with impulsiveness
Suicidal tendencies
Evaluation and Management
History
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
Evaluation and Management
History
Assessment
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
History
Assessment
Treatment: MDD in elderly patients with AD
Medications:
• Anti-depressants: low doses, increase slowly
• 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
History
Assessment
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
Evaluation and Management
History
Assessment
Treatment: MDD in elderly patients with AD
Medications
• Anti-depressants
• Anti-psychotics
• Anti-convulsants
• Minor tranquilizers →
• ↓ anxiety
• ↑ sedation
• ↓ cognition
Evaluation and Management
History
Assessment
Treatment: MDD in elderly patients with AD
Medications
Psychotherapy (slow, repetitive process)
• Supportive
• Behavior (statistically significant improvement)
• Family (especially with caregivers)
Evaluation and Management
History
Assessment
Treatment: MDD in elderly patients with AD
Medications
Psychotherapy
Management of suicidal behavior
Frequent assessment
ECT may be required
Summary
MDD frequently precedes or co-exists with AD
Diagnosis of MDD in elderly is inexact
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