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Depression is one of several mood and behavioral symptoms that can occur in patients with Alzheimer’s disease (AD). It is important to know the facts about depression and depressive symptoms in order to determine how to best manage them. The hallmark symptom of depression is depressed mood described as feeling sad, angry, down or blue and may or may not be accompanied by tearfulness and crying. Depression is the expression of these symptoms out of proportion and beyond the expected in response to a situation such as a death or other loss. The following is provided to clear up some misconceptions and provide a hint as to the best way to manage depression and its symptoms.

Misconception 1

Depression is rampant in late life, doctors rarely diagnose it and older adults rarely seek or receive treatment for it. This is a commonly stated perception of geriatric mental health. Is it true? The epidemiology of depression doesn’t change much in later life. The lifetime prevalence remains less than 5% (Beekman et al 1999; Snowdon 2001). Some studies have shown that depressive symptoms not adding up to full major depression syndrome are more common in late life with a prevalence between 9-14% (Lyness et al 1999). Nonetheless, the bottom line that can be inferred from this epidemiology is that growing older is not a harbinger of depression; the majority of adults will not develop a major depressive episode in late life. Yet, in this country older adults consume a grossly disproportionate amount of antidepressants: approximately one out of every three antidepressants.

In a recent study from patients participating in the National Alzheimer’s Disease Research Center brain bank about 10% of patients were reported to have Depression.

Misconception 2

Alzheimer’s disease causes depression. While almost all medical illnesses are associated with some increase in depressed mood there is no strong evidence that AD causes depression. However there is some evidence that depression may cause (or at least increase the risk of) Alzheimer’s disease. Several large studies have demonstrated that a life long history of depression as well as depressed mood is associated with an increased risk of Alzheimer’s disease. Also recent studies have shown that patients with AD who also have depression have more brain pathology than AD patients without depression. This includes more neuropathology in the hippocampus, the area of the brain associated with memory, and more neurofibrillary tangles in the frontal cortex, a part of the brain that is associated with executive function such as initiation and planning. It is not yet known if treating the depression lowers the pathology or the risk, but it seems clear that it is important to know if and when depression does occur.

Misconception 3

Depression is easy to diagnose so anyone can tell when a patient with Alzheimer’s disease is depressed. Actually it is not always easy to know when a patient is depressed. The diagnosis of depression hinges upon a patient’s self-report, elicited and interpreted by a doctor. In Alzheimer’s disease, patients may not spontaneously report their mood or they may not be able to recognize their feelings with a name or a good verbal description. Caregivers may interpret a patient’s words or behavior and report them to the doctor. This can increase the subjectivity and there are no objective blood, imaging or psychological tests. The diagnostic criteria are very broad.

A person with Alzheimer’s disease, like any other person, may or may not spontaneously report these symptoms but they can be elicited by asking. Several studies have demonstrated that with careful questioning depression can be reliably elicited from patients and their families and caregivers even in the moderately severe stages of the disease.

It can also be helpful to ask a patient why they are having such feelings. However it is important not to assume we already know the answer. For example, family members may think “of course the patient is depressed, he/she knows they have Alzheimer’s disease and it’s the end.” In fact, expressed sadness and irritability may really be a result of a worry over being sent away, frustration over inability to do usual activities, demoralization over not being permitted to do enjoyable activities, or fear over what will happen next. These concerns may be stated, elicited by questions, or observed as antecedents to expressed sadness. In patients with AD it is important to identify such fears, worries and frustrations because this information can direct treatment and management to address these concerns.

Misconception 4

Family caregivers are best at identifying depression. Not always. While family members are often the best informants to identify functional loss, depression may be more difficult for them to identify in a person with dementia. Alternately family members may assume the person with AD is depressed, based on their behavior. For example some patients experience apathy, loss of interest and withdrawal which may be associated with executive function loss, another cognitive symptom in AD. These symptoms may not be considered signs of depression if they occur without depressed mood.

In addition, we know that family members and caregivers may experience depression while caring for someone with AD and this may be the cause of their assumption that the patient is also depressed.

Misconception 5

Depression should be treated with medications such as anti-depressants. Not all reports of depression need to be treated pharmacologically. In some situations it can be useful to think of non-drug management strategies which may be helpful. There are three important steps to developing these types of approaches: (1) identifying the symptom, (2) understanding its cause, and (3) adapting the environment to remedy the situation. Correctly identifying what has triggered the depressed mood can often help in selecting the best intervention. If fear or worry about the future is a concern of the patient, it can be helpful to acknowledge the worry, by conveying compassion and empathy. It is also important to offer a positive perspective. Equally true and optimistic constructs can provide reassurance. For example, the worry that the memory loss might get worse is true but might be supported by the positive statement that friends and family will still be there for help and support.

Frustration can occur as the person with AD confronts what they can no longer do and can be the source of sadness or loss. Understanding this can provide mechanisms for adapting the environment to reduce the frustration. One way to help may be to simplify activities so they are more readily accomplished and can be pleasurable. Also, doing part of the activity for or with the person can be helpful.

Medications are indicated when the patient has a clinical depression. While recognition of this condition might be complicated by the Alzheimer’s patient’s difficulties with communication, there are indicators to look for: a pervasive sense of unhappiness, a persistent change in appetite, enjoyment, energy or interest. The patient may cry often, express a desire to die or even to kill him/herself. Suicide is a risk in patients with dementia. The risk might be greater in patients who have direct experience with caring for a relative with Alzheimer’s: these former caregivers at times think they want to avoid at all cost becoming like their affected relative. It is imperative that clinicians evaluating former caregivers of AD patients ask directly “What would you do if you were yourself diagnosed with Alzheimer’s?”

Medications used for major depression in any other clinical population or age group are likely to be equally effective in the Alzheimer’s patient with depression. Commonly used drugs for depression and irritability are: citalopram (Celexa^®), fluoxetine (Prozac^®), paroxetine (Paxil^®), and sertraline (Zoloft^®). These drugs must be given in adequate dose and usually require 6-8 weeks before achieving the maximal effect. If you suspect depression, it is worth speaking to a health care provider to carefully diagnose and treat this important disease.

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