Your Elderly Client: Is She Really Suffering From Dementia?
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One of the most common misdiagnoses in mental health is that of
dementia. This is not to say that dementia is not a real illness, or
that the elderly do not suffer from it in great numbers, but it is
to say that clients are not infrequently diagnosed as being demented
when in fact they are really depressed. Or they may be both
demented and depressed.
The reason for this diagnostic confusion is that many of the
symptoms of the two illnesses are similar, if not identical. But
since depression is treatable (whereas most forms of dementia are not),
it is critical that a careful, accurate and thorough assessment
be made of the elderly client. Moreover, the legal steps often
needed with a demented person (i.e. conservatorship or guardianship) are
not appropriate with someone who’s depressed. Depression and dementia
are two of the most common of all psychiatric disorders in those 65
years old and older. They’re often very difficult to tell apart, and
depression is not infrequently mistakenly diagnosed as dementia.
Research tells us that although mental disorders are not proportionately
more frequent in the elderly, a misdiagnosis with this population has
potentially more damaging consequences.
What Exactly Is
First, some background. Dementia is an organic disorder that may
be caused by many different factors, e.g. from a stroke, or a vitamin
deficiency, or an endocrine disorder or from HIV or Parkinson’s
Disease. Sometimes, as is the case with Alzheimer’s Dementia, the
underlying cause is not known. Depression, on the other hand, may have
some organic etiology but is more commonly thought of as a mood
disorder. Both the depressed and demented client are likely to show
impairments in thinking and memory. The depressed person, however,
is far more likely to acknowledge cognitive impairment, whereas the
demented person is more likely to try to minimize any problems. People
who are depressed usually don’t show noticeable mood swings, while those
with dementia may become irrationally angry or sad, for instance, and
display emotions inappropriate to the situation. Depressed people are
more likely to complain about their poor memory. They are more likely
to have fluctuations in their thinking abilities, and the onset of their
symptoms is more sudden. However, it is very important to note that
persons with dementia can also be clinically depressed. In fact, a
prior history of depression earlier in life dramatically increases the
possibility of dementia, and those with dementia are at a greater risk
for developing depression. In other words, one diagnosis does not
exclude the other!
A diagnosis of dementia means the individual has severe memory
deficits along with at least one problem in thinking, such as problems with
language, motor activities, inability to recognize familiar objects
and/or disturbance in higher cognitive processes (e.g. abstract
thinking, planning or organizing). If the client is younger than 50
years old and is displaying symptoms of dementia, it’s most likely due
to alcoholism or AIDS. If the client is older than 50, the incidence of
dementia increases markedly, and it’s most commonly due to problems in
metabolism, vitamin deficiencies, Parkinson’s Disease, alcoholism or
stroke (a.k.a. cerebral vascular accident).
Depression in the
elderly shows up differently
The symptoms most commonly associated with depression (i.e.
depressed mood or guilt) are less common with seniors. Instead, the
elderly tend to display physical symptoms such as problems with
sleeping, eating or lack of energy. They may start neglecting self-care
and become far less social. They are often apathetic towards life and
seem emotionally “flat.” This different presentation of depression in
the elderly is one key reason why the diagnosis is sometimes missed and
the symptoms attributed to other causes.
So how can anyone be sure what the correct diagnosis is? The
only certain way is a comprehensive psychological or neuropsychological
evaluation which includes psychological testing, a thorough taking of
the client’s history and gathering of collateral information from others
who know the client well. The consequences of not conducting an
exhaustive evaluation can be dire indeed, and could result in an
unnecessary loss of autonomy for the individual who is suffering from a
treatable depression, and NOT an ever-worsening dementia.
Boustani, M. and Watson, L. (2004) The interface of depression and
dementia. Psychiatric Times. March. Need page #sp. 46-9.
Gitner, G.G. (1995) Differential Diagnosis in Older Adults: Dementia,
Depression and Delirium. Journal of Counseling & Development.
January/February 1995. V. 73. p. 346-351.
Hill, C.L. and Spengler, P.M. (1997)Dementia and depression: A process
model for differential diagnosis.
Journal of Mental
January, 1997. V. 19 (1) p.23-40.
Janzing-Joost, G.E. (2003) Depression and dementia: Missing the link.
Current Opinion in Psychiatry January. 13-16.