Alzheimer's Society

Depression and dementia share many of the same symptoms. This can make it difficult to identify when people with dementia become depressed. This information sheet looks at depression and how it can affect people with dementia. It also suggests ways to help. 

What is depression?

We all feel low or down from time to time but this is not the same as experiencing depression. Depression is a more persistent condition in which a number of feelings, such as sadness, hopelessness or lack of energy, dominate a person's life and make it difficult for them to cope.

Depression is a common condition. At least one in five people in the UK will experience depression at some time in their lives. Depression is also common among people at all stages of dementia. It causes additional distress, making it even harder for people with dementia and those caring for them to cope.

Anyone with depression should see their doctor as soon as possible. The sooner depression is diagnosed, the easier it is to treat.

What are the symptoms?

Depression affects people in different ways and to different degrees. Doctors may talk about mild, moderate and severe depression. Some of the more common symptoms include:

• A sad, hopeless or irritable mood for much of the time
• Increased anxiety
• A loss of interest or pleasure in activities that were once enjoyed
• Feelings of low self esteem, worthlessness or undue guilt
• Feelings of isolation and of being cut off from other people
• Sleep disturbance, such as early waking
• Problems with remembering, concentrating or making simple decisions
• Slowing down in mind and body, or increased agitation and restlessness
• Eating too little or too much, and weight loss or gain
• Aches and pains that appear to have no physical cause
• Thoughts of death and suicide.

Some of these symptoms are similar to those experienced by people with dementia.

What causes depression?

There can be many different causes of depression, and they vary from person to person. There are often several contributory factors, including:

• Stressful or upsetting events, such as bereavement, a move or a disability
• The effects of certain illnesses or the side-effects of medication
• Feelings of loneliness and isolation
• Lack of activities, with feelings of boredom and aimlessness, and little control over situations
• Worries over issues such as money, relationships or the future.

In addition, some people may have a genetic predisposition to depression.

What treatment is available?

The main treatments for depression include antidepressant medication and psychological therapies (see Treatment, below).

Depression or dementia?

Because the symptoms of depression and dementia are often so similar, an older person with dementia may sometimes be wrongly thought to have depression, and vice versa. It is important to ensure that the person sees their doctor as quickly as possible so that an accurate diagnosis can be made, and appropriate treatment prescribed. If the doctor is uncertain, they may consider treating the person for depression and also referring the person to a dementia specialist.

Differences in symptoms between depression and dementia include:

• A depressed person's powers of reasoning and ability to orientate themselves as to time and space usually remain intact, although they can be impaired by the depression, while a person with dementia's are likely to be impaired
• A depressed person will usually complain of an inability to remember things but will remember when prompted, whereas a person with dementia will be forgetful but often try to cover up memory lapses.

Dementia accompanied by depression

Depression frequently co-exists with dementia. If people with dementia also become depressed they will be struggling with two lots of difficulties. The depression will exacerbate the effects of dementia making it even harder for people to remember things and making them more confused, more anxious or more withdrawn. It may also cause behavioural changes, such as walking around aimlessly, aggression, or refusal to eat.

It can be difficult to diagnose depression in dementia because some of the symptoms of depression and dementia are so similar, and because people with dementia may have difficulty explaining how they feel.

The causes for depression in dementia are likely to be similar to those for depression in general (see above). However, in the early stages they may also include worrying about memory loss and about no longer being able to cope as they had in the past. Chemical changes in the brain, caused by the dementia, may also lead to depression. People living in care homes seem to be particularly at risk of depression.

Consulting the doctor

It is important to let the doctor know straight away if the person with dementia is behaving in an unusual or worrying way, or has deteriorated more rapidly than you would have expected.

Since such changes could also be caused by an illness or by the effects of medication, the doctor will want to examine the person in order to rule out this possibility.

In order to try to diagnose whether or not the person is depressed, the doctor will talk to the carer and the person with dementia, where possible, to assess the person's mood and any changes that have occurred. For example, does the person seem more agitated or lethargic? Do they complain of feeling tired or hopeless? Do they look more depressed or cry more frequently? Are there changes in their sleeping or eating patterns or other behaviour? Do they still seem to enjoy the things they used to enjoy?

Treatment

Studies have shown that depression may respond to increased social support and attention to the person's environment (Teri, 1997 and 2003). This can be achieved by, for example:

• Pleasant activities that the person can still enjoy, such as short walks or outings.
• Making sure there is a reassuring daily routine
• Protecting the person from unwanted stimuli, such as bright lights, loud noises and too much rush and bustle, or from feeling isolated and bewildered in a large group
• More one-to-one interaction, such as talking, hand holding, or gentle massage, if appropriate.

Psychological therapies

Talking about feelings may be a helpful way of treating depression for people in the earlier stages of dementia. Increasingly, GP surgeries provide a counsellor or a counselling service. Counsellors are trained to listen and can provide a supportive environment for their clients. There are many different types of counselling therapies, and their suitability will depend on the person and the stage of their dementia.

Cognitive behavioural therapy can help to overcome the negative feelings that can sometimes be the cause of depression.

In psychotherapy, clients are encouraged to look deeper, uncovering the roots of their depression in their childhood experiences. There is now a small but growing body of evidence that people with dementia can be receptive to psychotherapeutic techniques (Cheston, 1998 and 2003).

Support groups may also be helpful. People usually find talking to others going through a similar experience immensely supportive.

Antidepressants

Antidepressants work by increasing the level of neurotransmitters (chemical messengers) in the brain. An imbalance or dysfunction of neurotransmitters can lead to depression.

Most antidepressants are not addictive and work well for the majority of people. They are usually taken for at least six months and often longer.

There may be side-effects to begin with, but these should lessen as the body adjusts to the drugs. The doctor may decide to change the dose or provide an alternative antidepressant if the side-effects continue.

There may also be a delay of two or three weeks before the effects of the drugs are felt, and response to the drugs is progressive over two or three months. It is important that the medication is taken as prescribed, even if the drugs do not appear to be working. Missing doses or stopping the drugs can effect the efficiency of the medication. There are many different types of antidepressants.

• Selective serotonin re-uptake inhibitors (SSRIs) are a newer class of drug. These include fluoxetine (Prozac), paroxetine (Seroxat), fluvoxamine (Faverin), sertraline (Lustral) and citalopram (Cipramil).
• There are other classes of non-tricyclic antidepressants, which are also claimed to be safer than tricyclic antidepressants. These drugs include mirtazapine (Zispin) and reboxetine (Edronax).
• Tricyclic antidepressants, such as amitriptyline (Lentizol), imipramine (Tofranil) or dothiepin (Dothiepin, Prothiaden), are 'older' antidepressant drugs. Side-effects include drowsiness, a dry mouth, blurred vision, constipation, and urinary retention. A side-effect to which the elderly are particularly prone is increased confusion. This type of drug should not be taken by people with dementia.
• Monoamine oxidase inhibitors (MAOIs) are sometimes prescribed for depression. It is important that a strict dietary regime is followed when taking these drugs, which usually makes them unsuitable for people with dementia. However, there is a newer class of 'reversible' MAOIs, which do not have the same dietary restrictions. A positive study has been carried out on one of these drugs, moclobemide (Manerix), in people with cognitive decline (Roth, 1996).

Useful organisations

British Association for Counselling and Psychotherapy (BACP)

BACP can provide a list of counsellors and psychotherapists in your area.

BACP House
35-37 Albert Street
Rugby
Warwickshire CV21 2SG

Telephone: 0870 443 5252
Email bacp@bacp.co.uk
Website http://www.bacp.co.uk/

Depression Alliance

Provides support for people with depression.

212 Spitfire Studios
63-71 Collier Street
London N1 9BE

Telephone: 0845 123 23 20
Email: information@depressionalliance.org
Website: http://www.depressionalliance.org/

Mind

Mind is the leading mental health charity in England and Wales. It publishes information on all aspects of mental health.

15-19 Broadway
London E15 4BQ

Telephone: 020 8519 2122
Mind Infoline: 0845 766 0163 (Monday-Friday 9.15-5.15; calls charged at local rate)
Email: contact@mind.org.uk
Website: http://www.mind.org.uk/

References

Cheston, R (2003) 'Group psychotherapy and people with dementia'. Aging & mental health 7(6):452-61

Cheston, R (1998) 'Psychotherapeutic work with people with dementia: a review of the literature'. British journal of medical psychology 71 ( Pt 3):211-31

Roth, M (1996) 'Moclobemide in elderly patients with cognitive decline and depression: an international double-blind, placebo-controlled trial'. British journal of psychiatry 168(2):149-57

Teri, L (2003) 'Exercise plus behavioral management in patients with Alzheimer disease: a randomized controlled trial'. JAMA 290(15):2015-22

Teri, L (1997) 'Behavioral treatment of depression in dementia patients: a controlled clinical trial'. Journals of gerontology series B-Psychological sciences & social sciences. 52(4):P159-66

Information sheet 444

Last updated: July 2006
Last reviewed: July 2006