There has been a much needed focused on dementia in recent years, resulting in some notable improvements in awareness and diagnosis. However, it is worth reflecting that depression is more common in old age than dementia and is particularly at risk of remaining untreated and underdiagnosed.
Although dementia and depression are distinct and different conditions, there are strong similarities in the way they present. Commonly, older people express concerns about their memory and their ability to do things. Dementia and depression share many symptoms, including anxiety, agitation, apathy, irritability, poor sleep, restlessness and difficulty concentrating. An older person with dementia may lose the ability to drive to the shops and accomplish tasks, an older person with depression may lose the motivation to do so, but the effect upon quality of life may be very similar.
We know that when older people develop depression (which 22 per cent of men and 28 per cent of women aged over 65), they usually don’t express it in the way younger people do. They may not talk about moods or how they feel. They are more likely to complain about their health in physical terms and about their ability to do things. Dementia is a brain problem that includes the impairment of memory and cognitive ability (knowing, understanding and reasoning). So both conditions can have the same effect of disrupting a person’s ability to accomplish basic day-to-day tasks.
Getting to the bottom of the root cause is essential as there may be a complex interaction of both issues. Dementia is frequently cited as the most feared health condition; it is recognised that people who have memory and functional ability impairment due may delay asking for help because they are frightened they could be told that they have dementia. In other words, an elderly person could struggle with untreated depression because they fear dementia. Equally, social workers have observed that the onset of dementia can produce an episode of depression; sadly, some individuals will be struggling with both.
The Mental Health Foundation provides a useful model of the five factors most closely related to depression in older people: physical health, poverty, relationships, participation in meaningful activities and discrimination. Some physical conditions, including vascular disease and diabetes increase the risk of depression, not only because of their psychological impact but also their direct effects on the brain. If an individual has had episodes of depression at a younger age in life, they are likely to be more vulnerable to the condition in old age.
Raising the subject of possible depression may be challenging or sensitive. Coming from a generation in which mental health was not openly discussed, they may feel very uncomfortable or embarrassed if asked directly about feelings. It may help to start with recognition of the factors which may be triggering their emotions (“I understand how much you must be missing playing golf with your friends”) to see if this opens up an avenue into a discussion.
The first practical step is going with your elderly relative to see their GP. Your GP will start with by taking a history, considering how the elderly person is functioning and feeling. Your GP may want to rule out other physical problems with a blood test. Some infections, diabetes or underactive thyroid can also produce symptoms of confusion and impairment of normal activities so will need to be ruled out.
There is no physical test for depression; it is diagnosed by careful history and discussion. If there is a suspicion of dementia, the elderly person is likely to have a neuropsychological tests (simple questionnaires to assess memory and cognition) and they may be referred for a brain scan.
Although this will be an anxious time for you and your relative, it is important to emphasise that not all memory problems are caused by dementia. If the changes they are experiencing are due to depression, they can be assured that there are very good treatments for depression and they will start to feel much better once treatment commences. They may need to face the very difficult diagnosis of dementia and although there is no cure, the importance of identifying the condition as soon as possible and starting treatment is well recognised. It is possible too that both depression and dementia are present, which will seem a very challenging diagnosis, but equally, the effected individual will be feeling very low and it is essential to have an accurate diagnosis and commence treatment and support as quickly as possible.