Depression in dementia: How do you know?
Jean Wendland Porter
Most of us have used or at least aware of the PHQ-9 (Patient Health Questionnaire) scale for depression. Through a series of questions that are directly related to the DSM-IV criteria, a patient or caregiver can determine whether they're depressed and how best to address their depression. It doesn't screen for depression, but can determine the level of severity of the already-diagnosed condition. It's used for those who are most at risk: post-stroke, post-cardiac event, etc.
The prevalence of depression in dementia patients has been estimated as high as 68%. This is not due to the usual changes in brain chemistry that one sees in an otherwise functional brain and that can be addressed with SSRIs. In a dementia patient, the depression can be caused by actual neuropathology that accompanies the plaques, tangles, and cerebral atrophy. The depression that the dementia patients suffer from can manifest itself differently: we may see increased behaviors instead of verbalized sadness.
Depression is one of the primary risk factors for dementia, as well as being a harbinger for dementia in later life.
The PHQ-9 asks subjective questions about pleasure in doing things, feeling depressed, sleep patterns, concentration levels, and suicidal ideation. Identifying those parameters can mean the difference between a life full of quality (and sometimes quantity), and a shortened life without meaning.
Using a depression screen like the PHQ-9 that is made for non-dementia patients may not be the best means of determining the possibility of depression in your patients. Yet we use it because it's there.
But what do you do with your dementia patients who may be depressed? Can they answer the questions honestly and accurately? Or do they just answer “yes” automatically to everything that's asked?
The Cornell Scale for Depression in Dementia (CSDD) was devised to determine whether and how dementia patients can be screened for depression, in a situation where they may not be able to accurately answer questions. It relies more on objective observation of behavior by a caregiver, and has been found to be an accurate screening tool.
- It defines Mood-Related signs such as appearance of anxiety, sad expression, lack of reactivity to pleasant events, and irritability.
- It defines Behavioral Disturbances such as restlessness, slow movement, physical complaints, and loss of interest.
- It defines Physical Signs such as loss of appetite and weight loss.
- It defines Cyclical Functions such as sundowning, sunrising, and difficulty falling asleep.
Using the CSDD, we are able to determine level of severity of depression in dementia patients without asking the subjective questions that are found in PHQ-9. Most of us know that our dementia patients may respond to pain differently than those who are more lucid. Pain in a dementia patient can manifest itself as crying spells, paranoia, aggression, crying out for help, and increased confusion (which results in anti-psychotic meds instead of pain meds.) Because the neuropathology in a dementia patient is different than in a non-dementia patient, their sensation of pain changes, and BPSD (Behavioral and Psychological Symptoms of Dementia) can also manifest.
These BPSD symptoms also occur with depression, and the CSDD measures and defines them. If we can monitor, observe, and utilize the correct medications to control pain and depression, which often look the same, we can decrease the anti-psychotic med use in our residents. As caregivers we always want to keep our residents functional, free of chemical restraints, and improve their quality and quantity of life.Jean Wendland Porter, PT, CCI, is the Regional Director of Therapy Operations at Diversified Health Partners in Ohio.