IntroductionThis is a case of a patient with history of dementia who presented with agitation. This case demonstrates that depression in a patient with dementia may not present with typical symptoms of depression as seen in the general population. Treatments may include behavioral and caregiver interventions in addition to medication.
History of Present Illness
The patient is a 77 year old man with past medical history significant for dementia, hyperlipidemia, coronary artery disease (CAD), s/p coronary artery bypass graft (CABG) and aortic valve replacement (AVR) who was referred to the Memory Clinic for agitation.
Assessment and Plan
Epidemiology of Depression in Patients with Dementia
Depression in older adults is estimated to range from 7-36 % in the outpatient setting , and in patients with dementia, the numbers range from 15-50 %. Depression in patients with dementia may go undetected due to the fact that the symptomology of depression in these patients manifest differently from cognitively normal patients.
Diagnosis of Depression in Patients with Dementia
Patients with Dementia May Have Different Clinical Manifestations of Depression
In a study comparing major depressive features between patients with Alzheimer’s disease (AD)* and cognitively normal older adults, several significant differences were noted in the study. Patients with AD had significantly diminished ability to concentrate or indecisiveness, less disturbances in sleep, and less reports of feelings of worthlessness or excessive guilt. However, patients with AD were noted to have higher rates of delusions and hallucinations. There was also a trend towards higher rates of psychomotor agitation/retardation and fatigue/loss of energy in more advanced AD patients. * .
Treatment of Depression in Patients with Dementia
Depression can be a contributing factor in functional decline in dementia, and treatment of depression may improve functional levels in these patients. Non-pharmacological Intervention
Non-pharmacological methods should be the first-line intervention in treatment of depression in patients with dementia. Interventions targeting the patient as well as the caregiver are important. These may range from arranging a day care for the patient to participate in activities to educating the caregivers on different care giving skills.
ANTIDEPRESSANT MEDICATIONS FOR DEPRESSION IN ADDrugInitial DoseMaximumDoseCommentsFluoxetine10 mg20–40 mgSSRIs in general: widely used due to favorable safety profile and effect on anxiety. Side effects include GI distress, anxiety, insomnia, medication interactions. FDA warning concerning emerging suicidality suggests careful monitoring in initial 10 days of treatment.Fluoxetine has long half-life with weekly preparation available but prolonged side effects.Sertraline25 mg150 mg(see fluoxetine).Paroxetine10 mg20–40 mg(see fluoxetine) May be calming and helpful for sleep.Citalopram10 mg20–40 mg(see fluoxetine).Escitalopram5 mg20 mg(see fluoxetine) Enantiomer of citalopram.Venlafaxine(long-acting)37.5 mg225 mgSide effect of hypertension (3%). More stimulating than SSRIs.Bupropion(long-acting)75 mg450 mgSide effect of seizures (at supra-therapeutic doses only). Dopaminergic effect may also be more stimulating than SSRIs.Mirtazapine7.5 mg30 mgSide effect of weight gain, sedation. Use at bedtime. Widely used as hypnotic.Nortriptyline10 mg100 mgSide effect of constipation, dry mouth. Best choice among tricyclic antidepressants due to favorable side effects profile.Methylphenidate5 mg in the morning10 mg at breakfast and lunchSide effects of insomnia, dyskinetic movements. May be helpful for apathy and fatigue. Limited research base.Duloxetine20 mgtwice daily40–60 mgtwice dailySide effect of hypertension less common than venlafaxine, sexual side effects less common than SSRIs. May be helpful for pain and somatizing syndromes.Rosenberg, P.B. and Lyketsos, C.B. 2006