Is your elderly client suffering from dementia?
Is your elderly client suffering from dementia?
Make sure it’s not depression
Many behaviors that get the elderly in trouble are not Alzheimer’s-related dementia but actually signs of depression that, if properly managed, not only correct behavioral problems but greatly improve the quality of life of many nursing home residents.
"The behaviors which often lead to nursing home referrals, such as verbal abusiveness and combativeness, are not behavioral problems associated with adult dementia are more often caused by depression," says Daniel Cowley, PsyD, a licensed psychologist with a mobile practice who consults on geriatric cases in North Carolina and South Carolina. "There are some commonalities in children and the elderly in terms of depression. A depressed child is often diagnosed as hyperactive: the child strikes out, acts aggressive or angry, and people think the child is acting out. The truth is that the hyperactive child often is a depressed child treated with the wrong class of drugs, and the same thing happens in the elderly."
Roughly 5% to 10% of nursing home residents are treated for depression, when the actual number of depressed nursing home residents is probably closer to 40%, says Cowley.
Unfortunately, dementia and depression often go hand in hand, adds Istvan Boksay, MD, PhD, director of the William and Sylvia Silberstein Aging and Dementia Research Center at the New York University Medical Center and chief of psychiatry and clinical associate professor in the department of psychiatry.
"It’s not uncommon for a patient to have a very mild dementia that’s not even diagnosable at this point. When these patients become depressed, their cognitive function worsens. Suddenly, you see a patient experience a dramatic decline which makes the dementia look much worse than it is. And, of course, many patients told they have Alzheimer’s react with depression. You tell some one that their mind is not functioning as it used to, it’s not surprising that it triggers a depression."
If the depression is treated early and aggressively, then the dementia improves and you see a return to baseline, says Boksay. (See tables, inserted in this issue, for California Workgroup on Guide lines for Alzheimer’s Management recommendations for treatment of dementia and depression. For more on the Guidelines for Alzheimer’s Management, see Case Management Advisor, August 1999, pp. 124-125.)
"If you treat the depression appropriately, you can reverse the decline. Once the depression is completely resolved, you must reevaluate the dementia and treat it, if necessary."
To make it even more difficult to recognize depression in the elderly, older Americans often don’t recognize they are depressed, adds Boksay. "They are 70 or 80 years old and have never seen a psychiatrist or a psychologist; they think they are just old and it’s normal to be sad. The food in the nursing home is lousy. They are becoming frail. The elderly will rarely tell you that they are depressed. You have to tell them and treat them anyway."
What are some possible indications that your elderly patient might need treatment for depression? Boksay agrees with Cowley that symptoms of depression often are overlooked or misunderstood. The elderly don’t exhibit the symptoms of depression seen in younger patients, such as loss of appetite, lack of sleep, and fatigue, they note.
If your patient appears to have an excess disability, suspect depression, says Boksay. "If you have been to the hospital and seen 10 patients recovering from a mild stroke. Nine of them are up walking around, and one refuses to get out of bed — [he is] impaired more than [his] medical condition seems to merit — depression may be present."
In addition, if your patient makes excuses for not resuming activity, don’t ignore it: Suspect depression. "Dementia doesn’t do that. Your patient with dementia may go in the corner and pee, but that patient won’t refuse to get up and walk to the corner," says Boksay.
Elderly patients treated with the wrong drug actually may exhibit drug-induced reactions with the appearance of dementia, which is the reason an accurate diagnosis by a geriatric psychiatrist or psychologist is so vital, cautions Cowley. "If a patient has a mild anxiety disorder but is treated with an antipsychotic drug, it often makes them look as if they have Alzheimer’s when they don’t," he says.
Depression also may be an important early clinical indicator of future Alzheimer’s in an elderly patient, which is just one more argument for early diagnosis and aggressive treatment of geriatric depression, adds Boksay. "Many older adults have age-related or mild forgetfulness, but only 50% of those older adults ever develop Alzheimer’s. It takes about five to seven years to develop Alzheimer’s. Now, we are able to better identify the 50% who will develop Alzheimer’s by identifying certain risk factors."
Those risk factors include:
• depression;
• family history of Alzheimer’s;
• poor blood flow;
• major medical problems;
• hypertrophy of the brain.
If you have an elderly patient with mild forgetfulness and at least one other risk factor for Alzheimer’s disease, Boskay suggests starting one of several drugs that slow cognitive and functional decline, such as cholinesterase inhibitors combined with vitamin E, or even some ginkgo biloba.
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