Depression of Alzheimer disease

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Depression is one of the most common psychiatric symptoms in Alzheimer's disease, occurring at all stages of the disease, but it often appears in a different form than other depressive disorders. In 2000, a workgroup of the U.S. National Institute of Mental Health created a set of provisional diagnostic criteria for depression of Alzheimer disease (dAD) as a separate diagnostic entity in its own right. [1]

Contents

In 2005, psychiatrists at Johns Hopkins University School of Medicine created a set of operationalized criteria to aid the diagnosis of dAD in clinical practice. [2]

Causes

Although caregivers often feel that the fact of an Alzheimer's diagnosis must be creating depression in the affected person, there is little or no evidence that this is true. [3] In fact, it is not clear how many people are capable of comprehending an Alzheimer's diagnosis at the time it is made. The symptoms of dAD can arise at any point during the course of Alzheimer's disease, often at a stage quite late in cognitive decline. [4]

Numerous neurological studies have found correlations between abnormalities in the brain and depression in dementia. For dAD in particular, positron emission tomography (PET) studies have found alterations of metabolism in the right superior frontal gyrus [5]

Symptoms

The diagnostic criteria for depression in Alzheimer disease specify that it requires only 3 of the possible symptoms for major depressive disorder (MDD), rather than the 5 required to diagnose MDD itself, and the symptoms may fluctuate. Therefore, dAD often goes unrecognized within the spectrum of symptoms of Alzheimer's disease. [4]

In general, people who have dAD tend to be anxious, agitated, delusional, or inattentive. Symptoms include irritability and social isolation. People with dAD are more likely than those with MDD to show a decline in their enjoyment of social contacts or customary activities, but are less likely to express or experience guilt or feel suicidal. [4]

Diagnosis

Of course, diagnosis must rely on the criteria established by the NIMH working group on dAD.

Because of the cognitive decline characteristic of Alzheimer's disease, diagnosis of dAD needs to include independent interviews of the patient and caregiver. The Cornell Scale for Depression in Dementia is particularly useful because it allows for these separate assessments. [6]

Treatment

Educating the caregiver about depression in dementia is of primary importance in addressing the problem. Caregivers need to understand the need for structure and comfort in the patient's daily activities, as well as the importance of including activities that the patient finds enjoyable and of trying to convey a sense of pleasure themselves. Caregivers also need an opportunity to "vent" and to understand and express when they have exceeded their ability to address the patient's needs. [4]

Psychosocial

Controlled trials show that providing pleasant daily activities [7] or exercise, [8] for someone who has Alzheimer's disease, in conjunction with activities designed to support the caregiver, can produce positive results in addressing the associated depression.

Medication

There are no official clinical guidelines as yet about the use of antidepressant medication for dAD in particular. Medication may be justified for people with diagnosed dAD who are suicidal, violent, not eating or drinking, or who score high on the Cornell scale.

The evidence would seem to suggest similar efficacy for SSRIs and tricyclic antidepressants in initial treatment for dAD. If these treatments do not address the symptoms, it would be reasonable to try noradrenergic drugs, secondary amine tricyclic antidepressants, or a monoamine oxidase inhibitor. [4]

A clinical trial testing sertraline (Zoloft) for depression of Alzheimer disease, launched by the NIMH in 2004, was due to be completed in the summer of 2009. [9] [ needs update ]

Sertraline, as per the latest studies has been found to be ineffective in improving cognitive outcomes in patients with Alzheimer's disease. [10] Sertraline is also associated with increased incidence of gastrointestinal and respiratory adverse effects. [11]

Related Research Articles

<span class="mw-page-title-main">Major depressive disorder</span> Mental disorder involving persistent low mood, low self-esteem, and loss of interest

Major depressive disorder (MDD), also known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities. Introduced by a group of US clinicians in the mid-1970s, the term was adopted by the American Psychiatric Association for this symptom cluster under mood disorders in the 1980 version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), and has become widely used since.

<span class="mw-page-title-main">Dementia</span> Long-term brain disorders causing impaired memory, thinking and behavior

Dementia is the general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities. This typically involves problems with memory, thinking, and behavior. Aside from memory impairment and a disruption in thought patterns, the most common symptoms include emotional problems, difficulties with language, and decreased motivation. The symptoms may be described as occurring in a continuum over several stages. Dementia ultimately has a significant effect on the individual, caregivers, and on social relationships in general. A diagnosis of dementia requires the observation of a change from a person's usual mental functioning and a greater cognitive decline than what is caused by normal aging.

<span class="mw-page-title-main">Sertraline</span> Antidepressant (SSRI class) medication

Sertraline, sold under the brand name Zoloft among others, is an antidepressant of the selective serotonin reuptake inhibitor (SSRI) class. The effectiveness of sertraline for depression is similar to that of other antidepressants, and the differences are mostly confined to side effects. Sertraline is better tolerated than the older tricyclic antidepressants. Sertraline is effective for panic disorder, social anxiety disorder, generalized anxiety disorder (GAD), and obsessive–compulsive disorder (OCD). Although approved for post-traumatic stress disorder (PTSD), sertraline leads to only modest improvement in this condition. Sertraline also alleviates the symptoms of premenstrual dysphoric disorder (PMDD) and can be used in sub-therapeutic doses or intermittently for its treatment.

<span class="mw-page-title-main">Dementia with Lewy bodies</span> Type of progressive dementia

Dementia with Lewy bodies (DLB) is a type of dementia characterized by changes in sleep, behavior, cognition, movement, and regulation of automatic bodily functions. Memory loss is not always an early symptom. The disease worsens over time and is usually diagnosed when cognitive impairment interferes with normal daily functioning. Together with Parkinson's disease dementia, DLB is one of the two Lewy body dementias. It is a common form of dementia, but the prevalence is not known accurately and many diagnoses are missed. The disease was first described by Kenji Kosaka in 1976.

Vascular dementia (VaD) is dementia caused by problems in the blood supply to the brain, resulting from a cerebrovascular disease. Restricted blood supply (ischemia) leads to cell and tissue death in the affected region, known as an infarct. The three types of vascular dementia are subcortical vascular dementia, multi-infarct dementia, and stroke related dementia. Subcortical vascular dementia is brought about by damage to the small blood vessels in the brain. Multi-infarct dementia is brought about by a series of mini-strokes where many regions have been affected. The third type is stroke related where more serious damage may result. Such damage leads to varying levels of cognitive decline. When caused by mini-strokes, the decline in cognition is gradual. When due to a stroke, the cognitive decline can be traced back to the event.

<span class="mw-page-title-main">Apathy</span> State of indifference, or the suppression of emotions

Apathy is a lack of feeling, emotion, interest, or concern about something. It is a state of indifference, or the suppression of emotions such as concern, excitement, motivation, or passion. An apathetic individual has an absence of interest in or concern about emotional, social, spiritual, philosophical, virtual, or physical life and the world. Apathy can also be defined as a person's lack of goal orientation. Apathy falls in the less extreme spectrum of diminished motivation, with abulia in the middle and akinetic mutism being more extreme than both apathy and abulia.

Dysthymia, also known as persistent depressive disorder (PDD), is a mental and behavioral disorder, specifically a disorder primarily of mood, consisting of similar cognitive and physical problems as major depressive disorder, but with longer-lasting symptoms. The concept was used by Robert Spitzer as a replacement for the term "depressive personality" in the late 1970s.

Alcohol-related dementia (ARD) is a form of dementia caused by long-term, excessive consumption of alcoholic beverages, resulting in neurological damage and impaired cognitive function.

Mild cognitive impairment (MCI) is a neurocognitive disorder which involves cognitive impairments beyond those expected based on an individual's age and education but which are not significant enough to interfere with instrumental activities of daily living. MCI may occur as a transitional stage between normal aging and dementia, especially Alzheimer's disease. It includes both memory and non-memory impairments. The cause of the disorder remains unclear, as well as both its prevention and treatment, with some 50 percent of people diagnosed with it going on to develop Alzheimer's disease within five years. The diagnosis can also serve as an early indicator for other types of dementia, although MCI may remain stable or even remit.

Pseudodementia is a condition where mental cognition can be temporarily decreased. The term pseudodementia is applied to the range of functional psychiatric conditions such as depression, schizophrenia and hysteria that may mimic organic dementia, but are essentially reversible on treatment. Pseudodementia typically involves three cognitive components: memory issues, deficits in executive functioning, and deficits in speech and language. Specific cognitive symptoms might include trouble recalling words or remembering things in general, decreased attentional control and concentration, difficulty completing tasks or making decisions, decreased speed and fluency of speech, and impaired processing speed. People with pseudodementia are typically very distressed about the cognitive impairment they experience. Two treatments found to be effective for the treatment of depression may also be beneficial in the treatment of pseudodementia: Cognitive behavioral therapy (CBT) which identifies behaviors that positively and negatively impact mood, and Interpersonal therapy which focuses on identifying ways in which interpersonal relationships contribute to depression.

The NINCDS-ADRDA Alzheimer's Criteria were proposed in 1984 by the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association and are among the most used in the diagnosis of Alzheimer's disease (AD). These criteria require that the presence of cognitive impairment and a suspected dementia syndrome be confirmed by neuropsychological testing for a clinical diagnosis of possible or probable AD; while they need histopathologic confirmation for the definitive diagnosis. They specify as well eight cognitive domains that may be impaired in AD. These criteria have shown good reliability and validity.

<span class="mw-page-title-main">Posterior cortical atrophy</span> Medical condition

Posterior cortical atrophy (PCA), also called Benson's syndrome, is a rare form of dementia which is considered a visual variant or an atypical variant of Alzheimer's disease (AD). The disease causes atrophy of the posterior part of the cerebral cortex, resulting in the progressive disruption of complex visual processing. PCA was first described by D. Frank Benson in 1988.

<span class="mw-page-title-main">Alzheimer's disease</span> Progressive neurodegenerative disease

Alzheimer's disease (AD) is a neurodegenerative disease that usually starts slowly and progressively worsens, and is the cause of 60–70% of cases of dementia. The most common early symptom is difficulty in remembering recent events. As the disease advances, symptoms can include problems with language, disorientation, mood swings, loss of motivation, self-neglect, and behavioral issues. As a person's condition declines, they often withdraw from family and society. Gradually, bodily functions are lost, ultimately leading to death. Although the speed of progression can vary, the typical life expectancy following diagnosis is three to nine years.

Sundowning, or sundown syndrome, is a neurological phenomenon associated with increased confusion and restlessness in people with delirium or some form of dementia. It is most commonly associated with Alzheimer's disease but also found in those with other forms of dementia. The term "sundowning" was coined by nurse Lois K. Evans in 1987 due to the timing of the person's increased confusion beginning in the late afternoon and early evening. For people with sundown syndrome, a multitude of behavioral problems begin to occur and are associated with long term adverse outcomes. Sundowning seems to occur more frequently during the middle stages of Alzheimer's disease and mixed dementia and seems to subside with the progression of the person's dementia. People are generally able to understand that this behavioral pattern is abnormal. Research shows that 20–45% of people with Alzheimer's will experience some variation of sundowning confusion. However, despite lack of an official diagnosis of sundown syndrome in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), there is currently a wide range of reported prevalence.

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<span class="mw-page-title-main">Melancholic depression</span> Medical condition

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References

  1. ↑ Olin JT, Schneider LS, Katz IR, et al. (2002). "Provisional diagnostic criteria for depression of Alzheimer disease". Am J Geriatr Psychiatry. 10 (2): 125–28. doi:10.1176/appi.ajgp.10.2.125. PMID   11925273.
  2. ↑ Rosenberg PB, Onyike CU, Porsteinsson AP, et al. (2005). "Clinical application of operationalized criteria for 'Depression of Alzheimer's Disease'". Int J Geriatr Psychiatry. 20 (2): 119–27. doi:10.1002/gps.1261. PMID   15660424. S2CID   39034731. Archived from the original on 2013-01-05.
  3. ↑ "Alzheimer's or depression: Could it be both?". Mayo Clinic. Oct 24, 2019. Archived from the original on 2014-01-07. Retrieved 2019-10-25.
  4. 1 2 3 4 5 Kozauer NA, Rosenberg PB, Lyketsos C (2006). "Depression in Patients with Alzheimer Dementia". Psychiatric Times. 23 (13).
  5. ↑ Lee DY, Choo IH, Jhoo JH, et al. (2006). "Frontal dysfunction underlies depressive syndrome in Alzheimer disease: a FDG-PET study". Am J Geriatr Psychiatry. 14 (7): 625–628. doi:10.1097/01.JGP.0000214541.79965.2d. PMID   16816017.
  6. ↑ Alexopoulos GS, Abrams RC, Young RC, et al. (1988). "Cornell Scale for Depression in Dementia". Biological Psychiatry. 23 (3): 271–284. CiteSeerX   10.1.1.461.315 . doi:10.1016/0006-3223(88)90038-8. PMID   3337862. S2CID   44280392.
  7. ↑ Teri L, Logsdon RG, Uomoto J, et al. (1997). "Behavioral treatment of depression in dementia patients: a controlled clinical trial". The Journals of Gerontology: Series B. 52 (4): 159–166. doi: 10.1093/geronb/52b.4.p159 . PMID   9224439.
  8. ↑ Teri L, Gibbons LE, McCurry SM, et al. (2003). "Exercise plus behavioral management in patients with Alzheimer disease: a randomized controlled trial" (PDF). JAMA. 290 (15): 2015–2022. doi: 10.1001/jama.290.15.2015 . PMID   14559955.
  9. ↑ "Depression in Alzheimer's Disease-2 (DIADS-2)". ClinicalTrials.gov. U.S. National Library of Medicine.
  10. ↑ Munro, CA; Longmire, CF; Drye, LT; Martin, BK; Frangakis, CE; Meinert, CL; Mintzer, JE; Porsteinsson, AP; Rabins, PV; Rosenberg, PB; Schneider, LS; Weintraub, D; Lyketsos, CG; Depression in Alzheimer’s Disease Study–2 Research, Group (Dec 2012). "Cognitive outcomes after sertaline treatment in patients with depression of Alzheimer disease". The American Journal of Geriatric Psychiatry. 20 (12): 1036–44. doi:10.1097/JGP.0b013e31826ce4c5. PMC   3508666 . PMID   23032478.{{cite journal}}: CS1 maint: numeric names: authors list (link)
  11. ↑ Weintraub, D; Rosenberg, PB; Drye, LT; Martin, BK; Frangakis, C; Mintzer, JE; Porsteinsson, AP; Schneider, LS; Rabins, PV; Munro, CA; Meinert, CL; Lyketsos, CG; DIADS-2 Research, Group (Apr 2010). "Sertraline for the treatment of depression in Alzheimer disease: week-24 outcomes". The American Journal of Geriatric Psychiatry. 18 (4): 332–40. doi:10.1097/JGP.0b013e3181cc0333. PMC   2849739 . PMID   20220589.{{cite journal}}: CS1 maint: numeric names: authors list (link)
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