Controversies in geriatric medicine
Depression and dementia. A review

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Abstract

Although dementia is primarily considered a memory disorder, there are significant neuropsychiatric manifestations sufficient to cause decline in ability to carry out social or occupational functioning independently. Depressive symptoms are extremely common in demented patients, and may be present very early in the course of the disease. To describe depression observed in patients suffering from dementia. Medline and Google Scholar searches were conducted for relevant articles, chapters, and books published before 2014. Search terms used included depression, dementia, behavioral and psychological symptoms of dementia (BPSD), Alzheimer's disease, dementia with Lewy bodies frontotemporal dementia, Huntington's disease, Parkinson's disease with dementia, vascular dementia. Publications found through this indexed search were reviewed for further relevant references. Depression and dementia are common in older people and their association is very complex. The reported prevalence of comorbid depression or depressive symptoms in individuals with dementia has been quite variable, likely due to differences in methods of assessment, diagnostic criteria, stages of dementia, and other factors. Little empirical evidence is available to guide the clinicians in the selection of treatment. Comorbid depression complicates diagnosis, affects treatment approaches and outcomes, and decreases the quality of life of affected individuals as well as their caregivers. The coexistence of depression and dementia has emerged as a significant public health problem leading to increased health care utilization and costs.

Introduction

Dementia is a brain disorder causing progressive change in cognitive functions, such as memory, language, rational thinking and social skills, as well as emotion and personality [1], [2], [3]. It presents a significant variability of clinical pictures. Many patients with Alzheimer's disease (AD) have depressed mood [1], and other behavioral symptoms [4], [5], [6], [7], [8]. Depression is also common in other types of degenerative dementias, including those that arise in frontotemporal dementia (FTD), Parkinson's disease dementia (PDD), Huntington's disease (HD), and in vascular dementia (VaD) [9].

Section snippets

Disease outcomes

Depression, when present with dementia, can adversely affect multiple areas of functioning in patients as well as caregivers. It is most strongly associated with reduced patient quality of life [10], and has been shown to have a negative impact on patients’ activities of daily living, even after adjusting for degree of cognitive decline and medical conditions [11], [12]. There are increased chances of early institutionalization of dementia patients with comorbid depression [13], and greater

AD

Depression is often seen early in the course of AD. Studies have reported that the rates of depression in AD range anywhere from 1% to 90% although most estimates fall between 30% and 50% [23] (Table 1). A significant source of variability arises from differences in the tools used to assess for mood changes across studies [24]. Vilalta-Franch et al. [25] examined the prevalence rate of depression according to five different conceptualizations [diagnostic criteria of ICD-10 [26] and DSM–IV [27]

Depression as risk factor or prodrome of dementia?

Whereas depression earlier in life would not be confused with dementia, early symptoms of dementia in older adults could be misdiagnosed as depression. The relationship between depression and the risk for later development of dementia is yet unclear. A personal history of depression has been related to increased risk for developing AD later in life, although this finding has not been universal. One study found that the risk of dementia among members of an AD registry was approximately twice as

Aetiology and pathophysiology

The heterogeneity of late-life depression and its association with cerebrovascular risk factors [89], physiologic changes related to aging [90], serotonergic dysfunction [91], structural brain changes [92], suggest that clinical expression of dementia may be related to a confluence of brain insults and diminished cognitive reserve. Underlying mechanisms, which may be associated with both dementia and depression, are neurotransmitter changes. Reduced levels of brain serotonin (5-HT) and

Assessment

The diagnosis of depression is based on the presence of a set of signs and symptoms that make up a continuum from lesser to greater intensity and frequency. An issue under debate is how to diagnose depression in the context of a chronic neurological illness that involves cognitive decline and prominent behavioral changes. As the dementing illness progresses, the presentation of depression may alter, with non-verbal manifestations (e.g. demanding behavior, clinging) being more apparent than

Management

Common sense would suggest that the initial management of depression in dementia should first of all involve consideration of precipitating factors such as life events or concomitant medication and also the nature of the living situation, both physically and socially [130]. When treating depression in healthy adult population, the clinician can choose from a range of interventions, from pharmacological to cognitive behavioral therapies. Although there is a wide evidence base for the use of

Conclusions

The diagnosis of depression in dementia is not an easy task. Depression and dementia are common in older people and their association is very complex. They contribute to suffering in both patients and their caregivers. It is still unclear whether depression is an early sign, a reaction to cognitive decline, a threshold lowering or possibly even a causal factor in AD. The prevalence of depressive symptoms and syndromal depression in dementia, ranging from 0% to 87%, depends on the scales used

Ethical statement

Research consists basically of a review of the literature and then it does not need the approval of the Ethics Committee.

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.

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