Depression and anxiety
Depression and anxiety are common conditions that are frequently experienced by people with dementia and their carers. They are known as psychological conditions because they can affect a person's emotional and mental health. This factsheet looks at how depression and anxiety can affect people with dementia. It also suggests ways for carers to help and looks at how depression and anxiety can be treated.
Most people 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 of depression are more common in older people with the condition.
At least one in five people in the UK will experience depression at some time in their lives. It is more common among people with dementia (20 to 40 per cent of whom may have depression), particularly those who have vascular dementia or Parkinson's disease dementia. Depression is often diagnosed in the early stages of dementia, but it may come and go, and may be present at any stage. Depression is also common among carers supporting a person with 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 morning 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 (eg problems with memory or concentrating and withdrawal) are similar to those experienced by people with dementia. This is why assessment of someone for possible dementia will usually include ruling out depression first, in case depression alone, rather than dementia, is causing their symptoms.
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 changes 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 - this is characterised by panic attacks in which 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 about 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 agoraphobia (a fear of open spaces).
- 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 those without, affecting between five and 20 per cent. Like depression, anxiety is thought to be more common in vascular dementia, and probably also in Parkinson's disease dementia, than in Alzheimer's disease. Anxiety is common throughout the different stages of dementia.
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 excessively worried, tired, restless and irritable, experiencing feelings of dread and having problems concentrating
- physical symptoms - fast or irregular heartbeats (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 and anxiety may also show behavioural symptoms including agitation, hoarding, seeking constant reassurance, not wanting to be left alone or closely following their carer or family member 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 - agitation may be caused by pain, hunger or an infection, for example
- lack of social support or social isolation - perhaps because the person can no longer get out as much
- lack of meaningful things to do, 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 has dementia can be similar to those for someone without dementia. However, in the early stages of dementia these conditions may be linked to a person's worries about their memory and about the future. People often retain their insight and awareness better in vascular dementia than in Alzheimer's disease, and this may partly explain why depression and anxiety are more common here. Damage to nerve pathways caused by reduced brain blood flow (vascular disease) is thought to cause depression in some people. 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. As dementia progresses, people become more disorientated, more forgetful and worse at thinking things through. Constantly struggling to make sense of the world around them can be a cause of anxiety.
A person with depression should be offered a range of treatments (self-help, talking therapies and/or antidepressant medication) depending on how severe or long standing their depression is.
For mild depression, which may lift by itself over time, the preferred approach is often self-help (eg promoting exercise) or a support group. If someone has severe or persistent depression, the GP will generally prescribe antidepressant medication, together with or followed by a referral for talking therapy, such as cognitive behavioural therapy (CBT). Between these two extremes, someone with moderate depression may be offered a talking therapy, an antidepressant or both. These approaches - especially an antidepressant combined with a talking therapy - are often effective, but they all take time to work: a few weeks, rather than a few days.
The same principles apply to treating depression in a person with dementia, although dementia does complicate matters. For example, a person with dementia may not be able to benefit from talking therapies because of their reduced attention, communication, memory or reasoning. Use of antidepressants as the first treatment for people with dementia is also widespread, but such drugs seem to be much less effective in people with dementia than in people without.
Guided self-help, activities and lifestyle changes
These approaches for dementia with mild depression do not require a counsellor, psychotherapist or doctor to deliver them, although professional guidance is still likely to be very helpful. Studies show that people with depression and dementia may respond to:
- regular physical exercise, such as short walks, tai chi or whatever is appropriate to the person's level of mobility
- a reassuring daily routine
- planning in regular activities with other people (social isolation can make depression worse)
- increased time spent doing enjoyable activities - examples include reminiscence and life story work (in which the person sits with someone to build a scrap book or photo album of their life)
- more one-to-one interaction, such as talking, hand holding, or gentle massage, if appropriate
- changes to the person's environment - examples of this include reducing unwanted stimuli, such as bright lights, loud noises or the rush and bustle of a large group.
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 (0300 222 1122).
Psychological therapies (talking therapies)
Psychological therapies or talking therapies are those that encourage people to talk about their feelings. Talking therapies are based on a model of how the mind works and are delivered by a counsellor, psychotherapist or other professional with training and a recognised qualification.
There is some evidence that sessions of talking therapy, given over several weeks, reduce depression and anxiety in people with dementia, particularly in the early stages of the condition. The therapy usually needs to be modified to suit the person's level of communication, understanding and memory. A therapist who has experience of working with people with dementia is therefore likely to be best. Talking therapies may be less appropriate in the later stages of dementia, when problems with attention, communication, understanding and memory are common.
There are many different types of talking therapies available, including counselling, interpersonal therapy and 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. Availability of suitable talking therapies varies and older people are less likely to receive a talking therapy than younger people, particularly those with depression living in care homes. For more information see factsheet 445, Talking therapies (including counselling, psychotherapy and CBT).
It is thought that depression is caused by low levels of certain chemicals, known as neurotransmitters, in the brain. Antidepressants are thought to boost the levels of these neurotransmitters, which helps to restore brain function. Someone with depression and dementia is likely to be offered antidepressant medication, particularly if the depression is severe or has not responded to other treatments. However, the evidence that antidepressants work in people with dementia is not conclusive: two recent trials reported no overall benefits on symptoms of depression from two widely-used drugs in people with Alzheimer's disease.
When someone takes antidepressants, the dose will be started low and gradually increased, and there may be a delay of several weeks before the person feels any benefits. There may also be side-effects to begin with, possibly more often than in a younger person, but these should lessen as the body adjusts to the drugs. If the side-effects continue, the doctor may decide to change the dose or provide an alternative antidepressant. 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. For this reason, antidepressants should always be withdrawn slowly.
There are many different types of antidepressants, including:
- SSRIs and SNRIs - SSRI (selective serotonin reuptake 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). Most people with dementia who are prescribed an antidepressant are currently offered an SSRI (eg sertraline, citalopram) first.
- 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 diet must be followed when taking MAOIs, and these drugs should not be taken by people who have had a stroke or those with a history of heart disease.
The treatment of anxiety, like that of depression, follows a 'stepped' care approach. Mild anxiety in people with dementia is usually helped by listening and reassurance, adjustments to make their living environment calmer and safer, and an improved structure to everyday life (including exercise and activities which have meaning for the person).
More severe and persistent anxiety can respond to psychological therapies such as CBT (see 'Treating depression' above). There is also some evidence that music therapy with a qualified therapist reduces agitation, which can be a symptom of anxiety.
Medication may also sometimes be helpful. Common medications used to relieve anxiety include:
- Antidepressants - These drugs can help relieve anxiety as well as depression, although the evidence for their benefit in anxiety is limited. An SSRI, such as sertraline, is recommended to be tried first. 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 they 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 - This is a specific anti-anxiety drug. It works in a similar way to benzodiazepines but does not cause drowsiness and 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 generally 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 see the doctor if a 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. They will try 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 a person 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 (particularly Alzheimer's disease) 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. These problems are reversible with treatment or when the depression lifts, which is not the case with dementia.
- Lacking motivation to do things (apathy) 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 you can do to help feelings of depression and anxiety: tips for carers
Someone who is feeling depressed or anxious will often find the following helpful:
- Talking 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. (Patience and understanding will be more helpful than trying to get the person to 'cheer up'.)
- Being supported to maintain social contact with people - this will help to counter any feelings of isolation.
- Persevering with treatment - those close to the person should encourage them to keep taking their medication or seeing their therapist.
- Keeping active - physical exercise is good for relieving feelings of anxiety and depression, and can also help people with sleep problems. Supporting the person to do other activities that they enjoy will often also help.
- Eating a healthy diet - a poor diet can contribute to feelings of anxiety and depression, as can alcohol and caffeine. It is therefore 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, they should first speak to their doctor. Complementary and alternative therapies that may be of benefit include St John's wort, aromatherapy, massage and bright light therapy. (For more information see factsheet 434, Complementary and alternative therapies).
Other useful organisations
British Association for Counselling and Psychotherapy (BACP)
15 St John's Business Park
Leicestershire LE17 4HB
National body representing counsellors and psychotherapists. Can help you to find a suitable counsellor in your area.
Coliseum, Riverside Way
Surrey GU15 3YL
T 0844 8030 240
Website that includes a searchable database of counsellors and psychotherapists who are members of a recognised professional body. Also useful information about how talking therapies might be able to help.
9 Woburn Walk
London WC1H 0JE
Provides information and support services to people affected by depression.
PO Box 277
Manchester M60 3XN
Charity offering information and advice on all aspects of mental health. Provides a range of support services through local Mind associations.
Last reviewed: April 2015
Next review due: April 2018
Reviewed by: Dr Noel Collins, Consultant Old Age Psychiatrist, Surrey and Borders Partnership NHS Foundation Trust and Dr Claudia Cooper, Reader in Old Age Psychiatry, UCL and Honorary Consultant Old Age Psychiatrist, Camden and Islington NHS Foundation Trust
This factsheet has also been reviewed by people affected by dementia. A list of sources is available on request.