Depression and anxiety
Depression and anxiety are common psychological conditions that are frequently experienced by people with dementia and their carers. Psychological conditions are things that can affect our emotional and mental health. This factsheet looks at how depression and anxiety can affect people with dementia. It also suggests ways to help and looks at how depression and anxiety can be treated.
We all feel low or down from time to time, but this is not the same as being depressed. Depression is a more persistent condition in which a number of feelings, such as sadness and hopelessness, dominate a person's life and make it difficult for them to cope. People with depression may also experience physical symptoms, such as loss of energy and appetite changes. Physical symptoms are more common in older people with depression.
At least one in five people in the UK will experience depression at some time in their lives. Depression is common among people with dementia and their carers. It is particularly common in people who have vascular dementia or Parkinson's dementia.
What are the symptoms of depression?
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
- 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
- increased agitation and restlessness
- tiredness or loss of energy
- 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 of depression are similar to the symptoms experienced by people with dementia.
A person with both dementia and depression will be struggling with two lots of difficulties. They may find it even harder to remember things and may be more confused or withdrawn. Depression may also worsen behavioural symptoms in people with dementia, causing aggression, problems sleeping or refusal to eat. In the later stages of dementia, depression tends to show itself in the form of depressive 'signs', such as tearfulness and weight loss.
Anxiety is a normal feeling that everyone experiences now and again. In some people, however, these feelings can be very strong and persistent. This can interfere with a person's everyday life.
Anxiety is the main symptom of several different conditions including generalised anxiety disorder (GAD), panic disorder, phobias and obsessive compulsive disorder (OCD).
- Generalised anxiety disorder (GAD) - people with GAD feel anxious about a wide range of issues and situations. They find it hard to control their anxiety and feel anxious most of the time.
- Panic disorder is characterised by panic attacks - the person will get sudden, intense attacks of anxiety. The attack may be accompanied by feelings of losing control (or 'going crazy') and feelings that they are going to die, as well as physical symptoms such as trembling and sweating.
- Phobias - a phobia is an intense, irrational or disproportionate feeling of fear about a particular object or situation. Common phobias include social phobia (a fear of being around others) and arachnophobia (a fear of spiders).
- Obsessive compulsive disorder (OCD) - a person with OCD experiences intrusive thoughts and obsessive worries that make them feel anxious. Their anxiety is temporarily relieved when they carry out a compulsive behaviour or ritual (for example, washing their hands or carrying out some other activity a certain number of times).
About one in 10 people will experience an anxiety disorder at some point in their lives and many people will have more than one form. Anxiety is more common in people with dementia than people without dementia and is thought to be more common in vascular dementia than in Alzheimer's disease.
What are the symptoms of anxiety?
There is a large overlap in the symptoms of the different anxiety disorders. General symptoms of anxiety include:
- psychological symptoms - feeling worried, tired, restless and irritable, experiencing feelings of dread and having problems concentrating
- physical symptoms - fast or irregular heart beats (palpitations), shortness of breath, excessive sweating, dry mouth, trembling, dizziness, nausea, diarrhoea, stomach ache, headache, insomnia, frequent urination, excessive thirst, muscle tension or pains.
People with dementia may also show behavioural symptoms including agitation, hoarding and demanding constant company (not wanting to be left alone) or closely following their caregiver around. The person may also appear restless and pace or fidget.
Causes of depression and anxiety
Many of the things that can cause people to feel depressed can also cause people to feel anxious, and vice versa. The exact causes of these conditions vary from person to person and there are often several contributing factors.
Possible causes of depression and anxiety include:
- traumatic or upsetting events - these can trigger high levels of anxiety that continue long after the event is over
- the effects of certain illnesses or the side-effects of medication
- lack of social support or social isolation
- lack of activities, with feelings of boredom and aimlessness
- feeling stressed or worried over issues such as money, relationships or the future
- having a past history of depression or anxiety
- having a genetic predisposition to depression or anxiety.
The causes of depression and anxiety in someone who also has dementia are likely to be similar to those for depression and anxiety in general. However, in the early stages of dementia these conditions may be linked to a person's worries about their memory and about the future. Chemical changes in the brain, caused by the dementia, may also lead to depression or anxiety.
People living in care homes seem to be particularly at risk of depression. Anxiety in people living in care homes has been linked to unmet needs, including a lack of daytime activities and a lack of company.
Psychological therapies and antidepressants are the main treatments for depression. These treatments are most effective when they are used together. However, it is important to note that both approaches may take some time to work. Other things that may help are increasing the amount of time spent doing activities that the person enjoys, planning regular activities with other people (social isolation can make depression worse) and making changes to the person's environment. Examples of this include protecting the person from unwanted stimuli, such as bright lights and loud noises.
Psychological therapies allow people to talk about their feelings. This is helpful for those with depression and anxiety, and may be particularly helpful for people in the early stages of dementia. Talking therapies may be less appropriate in the later stages of dementia, when problems with communication are common.
There are many different types of talking therapies available, including counselling, psychotherapy and cognitive behavioural therapy (CBT). The type of therapy that will be most suitable will depend on what the person would like to get out of therapy and the stage of their dementia. (See factsheet 445, Talking therapies (including counselling, psychotherapy and CBT).)
Support groups, where people can talk to others who are going through a similar experience, may also be very helpful. For information about groups near you, contact Alzheimer's Society's National Dementia Helpline (0845 3000 335).
It is thought that depression is caused by low levels of certain chemicals (neurotransmitters) in the brain. Antidepressants are thought to boost the levels of these neurotransmitters, which helps to restore their function. Someone with depression and dementia is likely to be offered antidepressant medication, although the evidence that antidepressants work in people with dementia is patchy. (Two recent trials reported no consistent benefits on symptoms of depression from two drugs widely used in people with Alzheimer's disease.)
When someone is offered antidepressants, there may be a delay of several weeks before any beneficial effects are felt. There may also 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. Sometimes it is necessary for someone to try a few different types of antidepressant before they find one that is effective for them. Antidepressants are usually taken for at least six months and often longer. It is important that the medication is taken as prescribed, even if the drugs do not appear to be working.
Some people find that they have difficulty coming off antidepressants and may experience withdrawal symptoms, such as increased anxiety, if their antidepressants are suddenly stopped. This is probably because antidepressants and other psychiatric drugs lead to changes in the brain. When the drugs are suddenly removed, people can experience symptoms as their brain adapts. For this reason antidepressants should always be withdrawn slowly.
There are many different types of antidepressants, including:
- SSRIs and SNRIs - SSRI (selective serotonin re-uptake inhibitor) and SNRI (serotonin-norepinephrine reuptake inhibitor) drugs are commonly used treatments for depression. This is because their side-effects are usually less upsetting than those of other drugs, although they can produce headaches and nausea (especially in the first week or two of treatment).
- Older antidepressants - These include tricyclic antidepressants and MAOIs (monoamine oxidase inhibitors). They are less commonly used and are likely to increase confusion in people with dementia. Side-effects are common, especially in older people. A strict dietary regime must be followed when taking MAOIs and these drugs should not be taken by people who have had a stroke or people with a history of heart disease.
- pleasant activities that the person can still enjoy, such as short walks and outings or looking at photograph albums
- 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.
Mild anxiety in people with dementia is usually helped by reassurance, adjustments to their living environment or an improved structure to everyday life. More severe and persistent anxiety can be treated with psychological therapies (see 'Treating depression' above). Medication may also sometimes be helpful. Common medications used to relieve anxiety include:
- Antidepressants - These drugs can help relieve anxiety as well as depression. See above for information on the different types of antidepressants.
- Benzodiazepines - These are very effective at treating anxiety but should only be used for a short period (up to two weeks). When used for longer periods they are addictive and may cause unpleasant withdrawal symptoms when a person stops taking them. They are not usually suitable for people with dementia as they can cause excessive sedation (drowsiness), unsteadiness and a tendency to fall, and may worsen confusion and memory problems.
- 'Z' drugs (non-benzodiazepines) - These drugs are used to treat sleep problems which are common in both depression and anxiety. They have similar effects to benzodiazepines. Examples include zaleplon, zolpidem and zopiclone.
- Buspirone - A specific anti-anxiety drug. It works in a similar way to benzodiazepines but is not addictive. It should, however, still only be used for a short period of time.
- Antipsychotics - Antipsychotics are sometimes used for severe or persistent anxiety, but should be avoided for this purpose in people with dementia (for more information see factsheet 408, Drugs used to relieve behavioural and psychological symptoms in dementia).
Consulting the doctor
It is important to tell the doctor straight away if the person with dementia is behaving in an unusual or worrying way, or has deteriorated more rapidly than expected. Such changes could be caused by depression or anxiety, or could be due to an illness or the effects of medication.
In order to diagnose anxiety or depression, the doctor will talk to the person with dementia and their carer to assess the person's mood and any changes that have occurred (for example, have they become more agitated or do they have less energy?)
It can be difficult for a doctor to diagnose depression in people with dementia because the symptoms of depression and dementia are so similar. People with dementia may also have difficulty communicating their low mood or feelings of anxiety to others. Because of this, a person with dementia may sometimes be wrongly thought to have depression, and vice versa. Key differences in symptoms between depression and dementia are as follows:
- Depression tends to develop much more quickly than dementia (over weeks or a few months).
- Problems with speech, reasoning, and orientation in time and space are unusual in depression but are common in people with dementia.
- A person with depression may occasionally complain of an inability to remember things but will remember when prompted, whereas a person with dementia will be forgetful and will often try to cover up memory loss.
- Where people with depression do have very bad impairments in their reasoning and memory (for example, when depression is severe), this is mainly due to poor concentration and the problems are reversible with treatment or when the depression lifts. This is not the case with dementia.
- Lacking motivation to do things can be a symptom of both dementia and depression, however the person is likely to show other symptoms of depression (such as being tearful) if this is the cause.
What can you do to help feelings of depression and anxiety?
Someone who is feeling depressed or anxious may find it helpful to:
- keep active - exercise is good for relieving feelings of anxiety and depression, and can help people with sleep problems
- talk about their feelings - if someone is feeling depressed or anxious, or something very upsetting or traumatic has happened to them, they may find it helpful to talk to someone close to them about it
- eat a healthy diet - a poor diet can contribute to feelings of anxiety and depression, as can alcohol and caffeine. It is therefore also a good idea to try to eat a healthy diet and not drink too much alcohol or caffeinated drinks.
Some people may also want to try complementary and alternative therapies. If a person would like to access these therapies, they should first speak to their doctor. Complementary and alternative therapies that may be of benefit include St John's wort, aromatherapy, bright light therapy and pet therapy. (For more information see factsheet 434, Complementary and alternative therapies and dementia.)
Carers, friends and family can help someone who is feeling depressed or anxious by making sure that they:
- listen to the person
- spend time with the person
- ensure that the person is eating properly
- encourage the person to take their medication or see their therapist.
British Association for Counselling and Psychotherapy (BACP)
National body representing counsellors and psychotherapists. Can help you to find a suitable counsellor in your area.
Provides information and support services to people affected by depression.
Charity offering information and advice on all aspects of mental health. Provides a range of support services through local Mind associations.
Last reviewed: February 2012
Next review due: February 2014
Reviewed by: Dr Claudia Cooper, Senior Lecturer and Honorary Consultant in Old Age Psychiatry, University College London, London and Professor Cornelius Katona, Honorary Consultant in Old Age Psychiatry, Kent and Medway Paretnership Trust
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