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    Dementia Symptoms & Caregiver Strategies: Managing Depression in Cognitively Impaired Adults

    Depression is very common among people with cognitive impairment. Treatment is available and can make a significant difference in quality of life.

    Symptoms of depression
    It has been estimated that up to 40 percent of people with cognitive impairment suffer from significant depression. Examples of symptoms common to both depression and an underlying dementia include:

    • Apathy
    • Loss of interest in activities and hobbies
    • Social withdrawal
    • Isolation
    • Trouble concentrating
    • Impaired thinking
    In addition, cognitive impairment often makes it difficult for people to articulate their sadness, hopelessness, guilt and other feelings associated with depression.

    Depression in the elderly without sadness
    Depression in people who are cognitively impaired doesn't always look like depression in people who don’t have cognitive challenges. While depression and sadness might seem to go hand and hand, many depressed seniors claim not to feel sad at all. They may complain, instead, of low motivation, a lack of energy, or physical problems. In fact, physical complaints, such as arthritis pain or worsening headaches, are often the predominant symptom of depression in the elderly.

    Diagnosing depression with cognitive impairment
    There is no single test or questionnaire to detect depression. Diagnosis requires a thorough evaluation by a medical professional, especially since side effects of medications and some medical conditions can produce similar symptoms.
    An evaluation for depression will include:

    • A review of the person's medical history 
    • A physical and mental examination Social withdrawal
    • Interviews with family members who know the person well

    Depression vs. cognitive impairment
    Since depression and dementia share many similar symptoms, including memory problems, sluggish speech and movements, and low motivation, it can be difficult to tell the two apart. There are, however, some differences that can help you distinguish between the two.

    Symptoms of DepressionSymptoms of Cognitive Impairment
    • Mental decline is relatively rapid
    • Knows the correct time, date, and where he or she is
    • Difficulty concentrating
    • Language and motor skills are slow, but normal
    • Notices or worries about memory problems
    • Mental decline happens slowly
    • Confused and disoriented; becomes lost in familiar locations
    • Difficulty with short-term memory
    • Writing, speaking, and motor skills are impaired
    • Doesn’t notice memory problems or seem to care

    Treating Depression
    Getting appropriate treatment for depression can significantly improve quality of life. The most common treatment for depression in the cognitively impaired involves a combination of medicine, counseling, and gradual reconnection to activities and people that bring happiness. Simply telling the person to "cheer up," "snap out of it" or "try harder" is seldom helpful. Depressed people are rarely able to make themselves better by sheer will, or without lots of support, reassurance and professional help.

    Medication to treat depression in cognitively impaired adults
    There are several types of antidepressants available to treat depression. Antidepressants called Selective Serotonin Reuptake Inhibitors (SSRIs) are often used for depressed individuals who have cognitive because they have a lower risk than some other antidepressants of causing interactions with other medications. As with any medication, make sure to ask about risks and benefits, as well as what type of monitoring and follow-up will be needed.

    Medical conditions can cause depression in the elderly
    It’s important to be aware that medical problems can cause depression in older adults, either directly or as a psychological reaction to cognitive changes. Any chronic medical condition, particularly if it is painful, disabling, or life-threatening, can also lead to depression or make depression symptoms worse. These include:

    • Parkinson’s disease
    • stroke
    • heart disease
    • cancer
    • diabetes
    • thyroid disorders
    • Vitamin B12 deficiency
    • dementia and Alzheimer’s disease
    • lupus
    • multiple sclerosis
    Prescription medications and depression in the elderly
    Symptoms of depression are a side effect of many commonly prescribed drugs. An individual is particularly at risk if he or she is taking multiple medications. While the mood-related side effects of prescription medication can affect anyone, older adults are more sensitive because, as we age, our bodies become less efficient at metabolizing and processing drugs.
    Medications that can cause or worsen depression include:
    • Blood pressure medication (clonidine)
    • Beta-blockers (e.g. Lopressor, Inderal)
    • Sleeping pills
    • Tranquilizers (e.g. Valium, Xanax, Halcion)
    • Calcium-channel blockers
    • Medication for Parkinson’s disease
    • Ulcer medication (e.g. Zantac, Tagamet)
    • Heart drugs containing reserpine
    • Steroids (e.g. cortisone and prednisone)
    • High-cholesterol drugs (e.g. Lipitor, Mevacor, Zocor)
    • Painkillers and arthritis drugs
    • Estrogens (e.g. Premarin, Prempro)
    If your loved one feels depressed after starting a new medication, talk to their doctor. They may be able to lower dosages or switch to another medication that doesn’t impact mood.

    Non-drug approaches

    • Support groups can be very helpful, particularly with those who are aware of their diagnosis and prefer to take an active role in seeking help or helping others; individual counseling is also an option, especially for those people who aren't comfortable in groups
    • Schedule a predictable daily routine, taking advantage of the individual's best time of day to undertake difficult tasks, such as bathing
    • Make a list of activities, people or places that he or she enjoys and schedule these things more frequently
    • Help the person exercise regularly, particularly in the morning
    • Acknowledge the person's frustration or sadness, while continuing to express hope that he or she will feel better soon
    • Celebrate small successes and occasions
    • Find ways that the individual can contribute to family life and be sure to recognize his or her contributions
    • Provide reassurance that the person is loved, respected and appreciated as part of the family, and not just for what she or he can do now
    • Nurture the person with offers of favorite foods or soothing or inspirational activities
    • Reassure your loved one that he or she will not be abandoned
    Helping a depressed cognitively impaired friend or relative
    If a cognitively impaired person you care about is depressed, you can make a difference by offering emotional support. Listen to your loved one with patience and compassion. Don’t criticize feelings expressed, but point out realities and offer hope. You can also help by seeing that your friend or family member gets an accurate diagnosis and appropriate treatment. Help the depressed individual find a good doctor, accompany him or her to appointments, and offer moral support.
    • Invite your loved one out. Depression is less likely when people’s bodies and minds remain active. Suggest activities to do together that your loved one used to enjoy: walks, an art class, a trip to the museum or the movies—anything that provides mental or physical stimulation.
    • Schedule regular social activities. Group outings, visits from friends and family members, or trips to the local senior or community center can help combat isolation and loneliness. Be gently insistent if your plans are refused: depressed people often feel better when they’re around others.
    • Plan and prepare healthy meals. A poor diet can make depression worse, so make sure your friend or family member is eating right, with plenty of fruit, vegetables, whole grains, and some protein at every meal.
    • Encourage the person to follow through with treatment. Depression usually recurs when treatment is stopped too soon, so help the individual keep up with his or her treatment plan. If it isn’t helping, look into other medications and therapies.
    • Make sure all medications are taken as instructed. Remind the person to obey doctor's orders about the use of alcohol while on medication. Help the person remember when to take their dose(s).
    As a caregiver, if you see signs of depression, discuss them with your friend or family member’s primary care doctor. Proper diagnosis and treatment can greatly improve your loved one’s sense of well-being and function.

    Cognitive Impairment can have many causes. The patient’s doctor should be consulted to determine a specific diagnosis and treatment options. But whatever the cause, the symptoms are often alike, and the Caregiver Strategies are often similar.

    The information in the resources listed above was compiled by the Ray Dolby Brain Health Center through clinical experience and commonly available published materials. For information on additional Caregiver Strategies, go to: cpmc.org/brainhealth.