Depression

Depression and dementia share many of the same symptoms. This can make it difficult to identify depression in people with dementia. This factsheet 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.

The causes for depression in someone who also has dementia are likely to be similar to those for depression in general. However, in the early stages the person may also worry 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.

Depression or dementia?

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effects of the dementia, making it even harder for them to remember things, and making them more confused, anxious or withdrawn.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

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 soon 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 them to a dementia specialist.

Differences in symptoms between depression and dementia are as follows:

• In depression, even when severe, other impairments typical of dementia (such as in speech, powers of reasoning and ability to orientate themselves in time and space) are unusual. In contrast, in a person with dementia these abilities are likely to be impaired. This can help a doctor to determine whether someone's problems are due to dementia.
• A depressed person will 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 lapses.
• In severe depression, the powers of reasoning and memory may be very badly impaired, and it is this state that is most easily confused with dementia. However, in a person with depression this impairment is mainly due to poor concentration, and the condition is reversible with treatment or when the depression lifts. This is not the case with dementia.

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 person with dementia, where possible, and the carer, 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?
• Have there been changes in their sleeping or eating patterns, or in their other behaviour?
• Do they still seem to enjoy the things they used to enjoy?

What treatment is available?

The main treatments for depression include psychological therapies, antidepressants, and social support or attention to the person's environment.

Psychological therapies

For people in the earlier stages of dementia, talking about feelings may be a helpful way of treating depression.

• Counselling is increasingly offered through GP surgeries. 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. (See Factsheet 445, Counselling: how can it help?)
• Cognitive behavioural therapy can help to overcome the negative feelings that can sometimes be the cause of depression, and is often available on the NHS.
• Support groups may also be helpful. People usually find talking to others who are going through a similar experience immensely supportive. For information about groups near you, contact the Alzheimer's Society National Dementia Helpline (details at the end of this sheet)

Antidepressants

Antidepressants work by prolonging the activity of neurotransmitters (chemical messengers) in the brain. It is thought that a dysfunction of neurotransmitters may be associated with depression.

Most antidepressants work well for a lot of people. They are usually taken for at least six months, and often longer. Some people find that they have great difficulty coming off them, so antidepressants should always be withdrawn slowly. People may have to try one or two different brands before they find one that is effective for them. 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 affect the efficacy of the medication.

There are many different types of antidepressants, including:

• Selective serotonin re-uptake inhibitors (SSRIs) − These are used most commonly, because their side effects are usually better tolerated than those of other drugs, and they have the best evidence supporting their use (Lyketsos 2003). These include Prozac (the trade name for fluoxetine), Seroxat (paroxetine), Faverin (fluvoxamine), Lustral (sertraline) and Cipramil (citalopram).
• Other safer classes of antidepressants − There are some other classes of antidepressants that are also safer than tricyclic antidepressants (see below). These include Zispin (mirtazapine) and Edronax (reboxetine).
• Tricyclic antidepressants − These drugs, which include Lentizol (amitriptyline), Tofranil (imipramine) or Dothiepin, Prothiaden (dothiepin), have several common side-effects that can cause significant problems for older people, including urinary retention, blurred vision and drops in blood pressure, sometimes leading to falls. In addition, they can cause confusion even in older people without dementia, and therefore make the problems of those suffering from dementia even worse. This type of drug should not therefore be taken by people with dementia.
• Monoamine oxidase inhibitors (MAOIs) − These 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 one 'reversible' MAOI called Manerix (moclobemide) that does not require the same dietary restrictions. A positive study has been carried out on this drug in people with cognitive decline (Roth 1996).

Other approaches

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.

Your local Alzheimer's Society branch will always be willing to talk to you and offer advice and information to support your needs.

For more information, Dementia Catalogue, our specialist dementia information resources is available on the website at alzheimers.org.uk/dementiacatalogue

Useful organisations

Alzheimer's Society

Devon House
58 St Katharine's Way
London E1W 1JX
T 020 7423 3500
E info@alzheimers.org.uk
W alzheimers.org.uk

British Association for Counselling and Psychotherapy (BACP)

BACP House
35-37 Albert Street
Rugby CV21 2SG
T 0870 443 5252
E bacp@bacp.co.uk
W http://www.bacp.co.uk/
     http://www.counselling.org.uk/

National body representing counsellors and psychotherapists. Can provide a list of counsellors and psychotherapists in your area.

Depression Alliance

212 Spitfire Studios
63-71 Collier Street
London N1 9BE
T 0845 123 23 20
E information@depressionalliance.org
W http://www.depressionalliance.org/

Provides information and support services to those affected by depression.

Mind

Mind England
PO Box 277
Manchester M60 3XN
T 0845 766 0163 (Mindinfoline 9.15-5.15 weekdays)
E contact@mind.org.uk
W http://www.mind.org.uk/

Mind Cymru
Quebec House
Castlebridge
Cowbridge Road East
Cardiff CF11 9AB
T 02920 395 123
E contactwales@mind.org.uk
W http://www.mind.org.uk/

The leading mental health charity in England and Wales. It publishes information on all aspects of mental health and providing a range of support through 200 local associations.

References

Lyketsos CG, DelCampo L, Steinberg M, Miles Q, Steele CD, Munro C, et al (2003) 'Treating depression in Alzheimer disease: efficacy and safety of sertraline therapy, and the benefits of depression reduction: the DIADS'. Archives of General Psychiatry 60(7): 737-46

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): 159-66

Factsheet 444

Last updated: September 2008
Last reviewed: September 2008

Reviewed by: Alan Thomas, Senior Lecturer in Old Age Psychiatry, Institute for Ageing and Health, Newcastle General Hospital and Dr Katherine Darton, Information Officer, Mind