Depression among Alzheimer Patients: A Neurologist Answers Our Questions
In honor of Alzheimer Awareness Month I have been asked to contribute several articles on the connection between Alzheimer’s disease and depression and how depression can affect both patients and caregivers. In an interview with practicing psychologist Dr. Deborah Serani, we discussed how caregivers may be more at risk for developing a mood disorder and strategies to prevent stress, burn-out, and depression among caregivers. In a second post we talked about the early warning signs of depression in Alzheimer’s patients and how to prevent these symptoms from becoming entrenched. In this post we are going to continue the conversation about depression and Alzheimer’s disease with an exclusive interview with Dr. Nitin Sethi, a practicing neurologist in New York City. He is going to be answering questions about the nature of depression among Alzheimer patients.
Dr. Sethi, can you tell us a little about yourself?
I am a neurologist with interests in Clinical Neurology, Epilepsy (clinical neurophysiology) and Sleep Medicine. I am certified by The American Board of Psychiatry and Neurology (ABPN) and have further subspecialty boards namely ABCN General Clinical Neurophysiology Board with added competency in Epilepsy Monitoring and in Intraoperative Monitoring. I am currently Assistant Professor of Neurology at New York-Presbyterian Hospital, Weill Cornell Medical Center in New York City. The human brain has always fascinated me both in health and disease and I have written extensively about it. About 3 years ago I decided to start a blog (http://braindiseases.wordpress.com) and a website (http://braindiseases.info) with a goal to disseminate information about neurological diseases.
Q: Can you tell us about the different types of dementia including Alzheimer’s disease?
Dementia is a disorder in which a person has cognitive impairments in multiple domains. By that I mean that a patient with dementia has problems with memory (forgets things), language (speech gets sparse and content/vocabulary is reduced), calculation (person loses the ability to calculate: subtract, multiply etc), and abstract thinking. Depending upon what part of the brain gets affected, a patient with dementia may also suffer from personality changes and problems with executive functions like planning and other goal directed actions.
They may also experience what we neurologists refer to as Apraxias. Apraxia is an inability to do a learned act. Like for example you can tie your own shoelaces as it is an act you learnt as a small child. Now assume you have dementia. You may lose the ability to tie your shoes laces even though you are not weak and have full strength in your arms and legs. Patients with dementia may suffer from various kinds of apraxias. As the disease evolves the patient become dependent on caregivers for nearly all activities of daily living: cannot drive, cannot tie their shoelaces, cannot feed themselves or take a shower on their own.
There are many different types of dementia. These differ from each other in the cognitive domains affected, their clinical presentation, their etiopathogenesis and natural history. The common dementias are:
1) Alzheimer's dementia
2) Fronto-temporal dementia also referred to as Pick's disease
3) Multi-infarct dementia also called vascular dementia
4) Dementia associated with Parkinson's disease also called Parkinson's disease dementia (PDD)
5) Diffuse Lewy Body dementia
6) Primary Progressive Aphasia
7) AIDS dementia complex or HIV encephalopathy
8) Dementias associated with infections like syphilis
9) Reversible dementias like that due to hypothyroidism, deficiency of vitamin B12, thiamine (vitamin B1), hydrocephalus (normal pressure hydrocephalus)
10) Conditions which can mimic dementia example depression (pseudodementia)
Q: What are the some of the early symptoms of Alzheimer ’s disease?
Alzheimer's dementia is the most common primary dementia seen in the elderly age group. The onset of AD may be very subtle and frequently the caregivers or the patient cannot tell when the disease first began. By the time the patients come to medical attention, the dementia is usually prominent. A point to note here is that patients with dementia usually do not seek help by themselves. They do not feel anything is wrong with them, are not bothered by their lack of memory or their forgetfulness. It is their relatives and friends who first notice something is amiss. They notice that the patient keeps forgetting simple things, may get lost in their own neighborhood (for example the patient may not know what street he lives on and get lost while driving), other things like going to the grocery store and forgetting why one went there in the first place and having problems with names etc may be noticed.
Surprisingly in the earlier stages of the disease patients maintain their social graces. They may interact gracefully in a social setting like a party or at work and if you are inter-acting with them casually you may never realize that they are having memory problems.
Q: How is Alzheimer’s diagnosed?
The diagnosis of Alzheimer's disease is clinical and a neurologist is able to make the diagnosis clinically with a reasonable level of accuracy. Your doctor may order some tests like an MRI study of the brain and blood tests to measure the thyroid hormone levels in your body, vitamin B12 level and also to rule out diseases which can mimic Alzheimer's disease in its presentation such as syphilis. Nowadays more advanced imaging tests are increasingly used to diagnose Alzheimer's disease at an earlier stage of minimal cognitive impairment (MCI). These include PET (positron emission tomography) scan, SPECT (single photon emission computed tomography) scan and fMRI (functional MRI) scans. These facilities are only available in big tertiary care centers of the country.
Q: What are the possible treatments for Alzheimer’s disease? Do any supplements help?
Alzheimer's dementia is as of now incurable. The disease is further relentlessly progressive. However there are medications which can slow the progression of this neurodegenerative disease and improve the cognitive abilities of the patients. These drugs belong to a class of drug called cholinesterase inhibitors. They inhibit the cholinesterase enzyme from breaking down acetylcholine, thus increasing both the amount and duration of action of the neurotransmitter acetylcholine. Commonly prescribed drugs include donepezil (Aricept), rivastigmine (Excelon), tacrine (tetrahydro aminoacridine) and galantamine. A few years ago, a new drug called memantine (Nemanda) was introduced into the market. This has a different mechanism of action as compared to the cholinesterase inhibitors. It is an orally active NMDA receptor antagonist.
Treatment with the above medications does not alter the natural history of Alzheimer's dementia. The disease progresses but patients may possibly obtain a few more years of relatively preserved cognitive abilities. Caregiver burden is reduced since patients may remain independent in some activities of daily living.
Certain other medications and nutritional supplements have been advocated for Alzheimer's disease patients with no proven efficacy. These include supplements like Ginkgo biloba and supratherapeutic doses of Vitamin E (1000 international units and above). In the more advanced stages of the disease, patient's become mute, akinetic (do not move spontaneously), they are doubly incontinent, cannot feed themselves and become totally dependent on caregivers. Caregiver burn out is quite common at this stage and patients may be placed in nursing homes. In this advanced stage urinary tract infections (UTI), respiratory tract infections (pneumonias) and bed sores (decubitus ulcers) are common causes of morbidity and mortality.
Q: Is there any neurological and/or biological connection between Alzheimer’s disease and depression?
Depression is a relatively common neurological condition. It may occur on its own (primary depression) or it may occur during the course of another acute or chronic neurological illness such as stroke or dementia. It is important that depression be recognized and treated since studies have shown that it increases the morbidity and mortality associated with these conditions.
The diagnosis of depression is essentially a clinical one. Certain clinical features which when present for a sufficient length of time (usually 2 weeks or more) suffice to make a clinical diagnosis of major depressive disorder (MDD). These features include what is called anhedonia (loss of pleasure in day to day activities), depressed mood (in children it may present as irritability), weight loss or weight gain, insomnia or hypersomnia (sleeping less or more than usual), changes in behavior and personality, feeling tired and fatigued, feeling of hopelessness and worthlessness and thoughts of death or suicide.
Sometimes it is difficult to weed out which symptoms are due to depression and which due to an organic brain disease such as dementia. Patients who have Alzheimer’s dementia, fronto-temporal dementia (Pick's disease), Parkinson's disease, frontal lobe strokes may look depressed. These patients are akinetic (do not move spontaneously), have mask like emotionless faces and do not talk readily (abulia). The point I am making is that depression may mask an underlying neurological condition like dementia or a frontal lobe tumor.
The reverse is also true. People who have neurodegenerative conditions such as Alzheimer’s dementia may have superimposed depression. Upon treating the depression they feel much better and may improve in caregiver rating scales.
The link between depression and dementia has and continues to be closely looked at.
Some of the questions we are trying to answer include:
–do attacks of major depression predispose to dementia later in life? (or put in more simpler terms, does depression hurt the brain and kills neurons leading to cerebral atrophy and dementia in later life?)
–is depression more common in patients with primary dementia such as Alzheimer’s dementia?
–is depression frequently missed or misdiagnosed in patients with primary dementia ?
–do patients with dementia have depression which is more refractory to medical treatment?
–does depression accelerate the rate of cognitive decline in patients with dementia?
Dementia patients may have superimposed depression and hence a thorough search should be made to rule out depression in a patient with dementia as it is readily treatable.
Q: As a doctor what questions do you ask of patients to determine if depression may be a factor in their condition?
Depression is a very common condition and I have learnt that if as a physician I do not look and ask about it, I am likely to miss it. So I invariably ask all my patients a few simple questions during the office interview. My screening questions are quite simple:
• Do you suffer from low mood?
• How is your energy level nowadays?
• What are your interests in life?
• Do you think you may be depressed?
If the patient or accompanying family member answers in the affirmative, I investigate them further for depression.
Q: Are depression symptoms any different for people having Alzheimer’s vs. those who do not suffer from dementia symptoms?
The symptoms of depression are essentially the same in patients who suffer from disorders of memory and those who do not. These symptoms include what is called anhedonia (loss of pleasure in day to day activities), depressed mood, weight loss or weight gain, insomnia or hypersomnia (sleeping less or more than usual), changes in behavior and personality, feeling tired and fatigued, feeling of hopelessness and worthlessness and thoughts of death or suicide.
Treatment of depression when it presents along or during the course of a neurodegenerative condition like Alzheimer’s dementia is essentially the same as treatment of primary depression. The most commonly prescribed drugs are those which belong to two classes: tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRI).
Q: Is it sometimes difficult to ascertain whether or not a patient with Alzheimer’s has depression?
It is indeed difficult to determine with certainty whether a patient with Alzheimer’s dementia also has superimposed depression. Also what is the optimum treatment for someone who might have an underlying primary dementia such as Alzhemier’s disease but also has superimposed incompletely treated depression? Most doctors would agree that her depression needs to be treated more aggressively and then the primary dementia should be reassessed.
Q: What expert advice do you give to your patients with Alzheimer’s or their caregivers when you suspect that your patient also has symptoms of depression?
I invariably advise aggressive treatment of the depression and then a reassessment of the patient’s cognitive status.
Q: Is there anything that the patient diagnosed with dementia symptoms or Alzheimer’s disease can do to prevent depression?
A very interesting question and let me answer it this way. Depression is bad for the brain and I strongly believe that a healthy brain and a healthy mind go hand in hand. You cannot have one at the expense of the other. Since depression is treatable and dementia as of now is not, it is very important that depression should be identified and aggressively treated in a patient suffering from disorders of memory.
Inner peace, calmness, introspection, tranquility are essential qualities that nurture the mind and help to maintain its internal equilibrium. Meditation, spirituality and doing yoga are ways by which that elusive inner peace can be obtained ensuring a healthy mind and brain.
Thank you for your thoughtful questions. I hope your readers find my answers equally insightful. Wishing you all a healthy brain and a healthy mind.
Nitin Sethi, MD Assistant Professor of Neurology
Course Director Resident Clinical Neurophysiology Rotation
New York-Presbyterian Hospital Weill Cornell Medical Center
Director and Chief Coordinator Brain Care Foundation (http://braincarefoundation.com)