Louis A. Cancellaro, PHD, MDProfessor Emeritus

Interim ChairJanuary 11, 2012

Depression in the Presence of Dementia:

A Diagnostic Challenge

EpidemiologyInexact diagnosis compromises researchMajor 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 ADPsychological

• Grief over loss of cognitive functionBiological

• 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

DiagnosisDiagnosing depression in elderly

• Inexact• Part of a continuum

• Sadness ↔ MDD ↔ Psychotic Depression• Frequently presents with somatic symptoms as

opposed to classical DSM IV criteria

DiagnosisDiagnosing 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

DiagnosisDiagnosing depression in elderly

• No precise diagnostic tests• Biochemical• Radiological• Psychological

Hamilton Depression Rating ScaleDSM-IV

Experienced clinicians are the most help

DiagnosisDiagnosing 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

DiagnosisDiagnosing depression and AD in elderlyEven more inexact, especially if signs of AD not

previously recognizedMDD 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”

DiagnosisDepression + 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

EpidemiologySuicide risk:

For all patients 65 years of age vs <65:• Rate =50% higher• Lethality =1 out of 2 attempts vs1 out of 8

Diagnosis

Dementia and Depression: Distinguishing Features

Feature Dementia Depression

Onset Unclear, insidious Clear, recent, often a major psychotic event

Progression Relatively steady decline Uneven, often no progression

Patient insight Often unaware of deficits, not distressed

Nearly always aware of deficits and quite distressed

Affect Bland, some lability Marked disturbanceTest Performance Good cooperation and

effort, stable achievement, little test anxiety, “near miss” responses

Poor cooperation and effort, variable achievement, considerable anxiety, “don’t know” responses

Short-term memory Often impaired Sometimes impaired

Long-term memory Unimpaired early in disease

Often inexplicably impaired

Differential DiagnosisEndocrine

Thyroid diseaseDiabetes MellitusCushing’sAddison’sHyperparathyroidism

Cardiovascular and pulmonary diseaseMICongestive heart failureCOPD

Differential DiagnosisEndocrineCardiovascular and pulmonary diseaseAnemia

• B12

Kidney and liver diseaseHepatitis C

InfectionsAIDS, TB, hepatitis, chronic fatigue syndrome, other chronic

infections

Differential DiagnosisEndocrineCardiovascular and pulmonary diseaseAnemiaKidney and liver diseaseInfectionsNeurological disease

CVA, low pressure hydrocephalus, Parkinson’s, subdural hematoma, sleep apnea, brain tumor, seizure disorder

Differential DiagnosisMedication side effects and interactions

PsychotropicsBenzodiazepinesAnti-psychoticsAnti-convulsantsAnti-depressants

Sleeping agentsPulmonary and cardiac drugsSteroids

Differential DiagnosisMedication side effects and interactionsOccult malignancy

Lymphomas, leukemias, multiple myelomaRetro-peritoneal tumors

Collagen vascular diseaseSLE, polymyalgia rheumatica, rheumatoid arthritis,

scleroderma, fibromyalgia Medications used in treatment

AlcoholismOther psychiatric disorders

Anxiety disordersMania

Evaluation and Management

Suspecting MDD either preceding or coexisting

with ADHistory (from patient and family)

Chief Complaint“Depressed” (less common)“Nerves”“Memory loss” Somatic symptoms (↓energy, GI symptoms,

weakness)

Evaluation and ManagementHistory

Chief ComplaintCourse of illness (one or more):

2 weeks↓interest in daily activities↓cognitive abilityPersonality change with impulsivenessSuicidal tendencies

Evaluation and ManagementHistoryAssessment

• 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 ManagementHistoryAssessmentTreatment: 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 ManagementHistoryAssessmentTreatment: 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

Evaluation and Management

Evaluation and ManagementHistoryAssessmentTreatment: MDD in elderly patients with AD

Medications Psychotherapy (slow, repetitive process)

• Supportive• Behavior (statistically significant improvement)• Family (especially with caregivers)

Evaluation and ManagementHistoryAssessmentTreatment: MDD in elderly patients with AD

MedicationsPsychotherapyManagement of suicidal behavior

Frequent assessmentECT 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

I, Louis A. Cancellaro M.D.

DO NOT have a financial interest/arrangement or affiliation with one

or more organizations that could be perceived as a real or apparent conflict of

interest in the context of the subject of this presentation.

Disclosure Statement of Financial Interest