How to navigate Depression and Dementia
This is a personal account of Sunday Care Therapy Founder Derek’s experience of caring with someone with Dementia, and dealing with depression:
My Aunt lives with me, presents with Dementia and I am her primary carer.
My background is Occupational Therapy, I have worked with a lot of people across my career who present with Dementia and likely were also experiencing Depression as well.
When I reflect on my interactions with people living with Dementia if I am honest, did I really consider their risk of also living with Depression and Anxiety? Probably not. Why? Because I didn’t know about it? Or was it that it wasn’t on the referral?
Either way, from my experience of now being a carer for someone with Alzheimer’s Dementia, who also experiences Anxiety and Depression, I see things differently. I can truly understand the importance of not only acknowledging the impact it can have on day to day living, but also the importance of actively trying to reduce the symptoms associated with Depression, Anxiety and Dementia.
Even as a Therapist I was shocked to read that statistically up to 40% of people living with all forms of Dementia could be at risk of also developing Depression (David Kitching 2015).
But even more shocking was the realisation that traditional medication prescribed for people experiencing Depression, such as but not limited to SSRI Antidepressants, not only were in-effective in reducing symptoms to improve quality of life and help with cognitive impairment, but people taking these medications were more likely only to experience the negative side effects associated with them (Dudas R, et al 2018).
So what we can deduce is that people living with Dementia are more like to experience Depression, and on top of this - the traditional antidepressants on offer are probably not the answer.
What else can we do about it?
First let’s try and understand what to look out for to give us an indication that someone is experiencing Depression, common symptoms associated with depression are:
Low mood
Sadness
Hopelessness
Loss of interest and pleasure in previously enjoyable activities
Difficulty with eating, either weight loss or weight gain
Difficulty with sleeping, such as insomnia, or excess sleeping
Psychomotor functions, either with decreased motor activity or hyperactivity.
There may also be feelings of low self-esteem, worthlessness, apathy and difficulty with personal interactions, such as withdrawing from family and friends.
These are some common symptoms associated with Depression, but Clinical Depression needs to be diagnosed by a Doctor. The difficulty with Dementia and a Clinical Depression diagnosis is, in order for a diagnosis to be given, the person should also have a presence of difficulty concentrating, memory complaints, slowed thinking, indecisiveness or a feeling of lack of control. These may be present regardless of Depression in someone living with Dementia.
If you feel your loved one or client has symptoms of Depression beyond the realm of Dementia it is important you discuss this with their GP.
It is super important as to understand the best way to support someone living with Dementia and experiencing depressive symptoms as well as to understand what type of Depression that person has. Is it a major depressive episode? Or adjustment disorder with depressed mood, another common type may be a mood disorder due to a medical condition with depressive features and dysthymic disorder.
As a health and social care provider in the community you can administer a screening tool for Depression such as Beck Depression Inventory or Zung Self-rated Depression Scale, to provide reasoning and evidence to contact the GP. As a carer or family member use your intuition if you know the person well and know something isn’t right contact the GP - it’s always better to be safe then sorry.
I had first hand experience of this when my Aunt, who is 91, started to present with Depression and Anxiety. The more I investigated this topic and the more professional courses I did as an Occupational Therapist in this subject, the more I realised the importance of supporting our older adults with Depression and neurocognitive disorders. Unfortunately, suicide in older people is statically a growing trend, with Dementia being seen as a risk factor for suicidal ideation and death by suicide (Serafini, 2016).
We have a professional, ethical and moral obligation to ensure we are identifying these symptoms as early as possible to ensure our patients and loved ones are getting the support they deserve and require.
As we have already seen, it may be difficult to tell the symptoms of Depression from the symptoms of Dementia. But we also need to take into account the symptoms of Delirium. So let’s look at each individually and see what is common and what is unique.
Dementia
Global cognitive decline
Initially is alert, attentive and has capacity, but will gradually develop decreased executive functional skills, memory loss and difficulty with movement
Delusions and may have hallucinations, depending on type of Dementia
Irritability may be present
Normal speech in early presentation to non verbal in late presentation
Slow onset, can be developing for many years
Memory loss
No clear pattern to symptom development
Depression
Disturbance in mood with low self-esteem
Poor attitude
Sadness/crying
Difficulty in experiencing pleasure.
Fatigue, insomnia, over sleeping
Difficulty with food relationships, over or under eating
Hopelessness/helplessness
Episodic subacute onset
No memory loss
Usually worse first thing in the morning
Delirium
Reduced level of consciousness
Drowsiness
Easily distracted and difficulty maintaining attention
Hallucinations common
Mood swings and lability
Sudden onset, could develop in hours
Slurred speech commonly present
Memory loss
Usually worse in the evening and at night
Now we have a better understanding of the differences in Depression and neurocognitive disorders and the importance of why we need to identify if someone is experiencing depressive symptoms.
What we can actually do?
From my experience with my Aunt, we decided not to go down the medication route, this is a personal choice. We had a conversation and made an informed decision to try other methods first. Again this is not for everyone and conversations should be held with health professionals and the individual before coming to your own decision on how to move forward.
What did we do?
We focussed on four areas:
Exercise and physical Activity
Breathing exercises
Social integration
Diet
Exercise and physical activity
First we looked at physical activity levels and exercise. When my Aunt was mobile, on the hour between 08.00 and 16.00 she would get up and walk from the lounge to the bedroom and back.
This doesn’t sound like a lot, but it increased her movement from just getting up to go to the toilet. When we started this, she required supervision and encouragement, but once she got the hang of it, she would do two rounds each go and also practice her sit to stand transfers on and off the bed. This was a dramatic increase in her physical activity. We also introduced in-chair exercises, simple movement patterns against gravity repeated up to 20 times, such as putting your hands on your knees to behind your head and back. Even now, when my Aunt is hoist dependant, she still does her chair exercises.
Exercise and physical activity has been shown to decrease Depression in older adults. It increases self-mastery, gives purpose and helps with efficacy of tasks as skills learnt and practiced are transferrable. Exercise also increases endorphin’s and monoamine transmitters in the brain which can help reduce Depression. Research has shown that exercise is comparable to using antidepressants to reduce depressive symptoms, with no negative side effects and with a more immediate effect. Both aerobic and resistance exercise have been shown to be beneficial (Catalan-Matamoros et al, 2016). It is also important to note that exercise is great for people with cognitive decline as physical exercise improves strength, balance, mobility and endurance (Lam et al, 2018).
Breathing exercises
Next we introduced some breathing exercise, very simple breathing in through the nose a short pause and out through the mouth.
This type of breathing is known to stimulate the parasympathetic nervous system to turn on our rest and digest response as opposed to the fight or flight. Studies have shown slow breathing techniques act enhancing autonomic, cerebral and psychological flexibility related to emotional control and psychological well-being (Zaccaro A, 2018). This study has been on healthy participants but from my experience translates well for other cohorts.
By introducing breathing techniques early with my Aunt in her cognitive decline journey, she has been able to maintain this exercise, so even now when doing something she finds stressful, we can concentrate on breathing to find a calm base.
Social integration
When I was working full time and my Aunt was being looked after by my partner (who works from home) and carers during the day, I would come home in the evening and not give my Aunt a lot of attention, mostly just go through the motions of preparing her food and supporting her to get ready for bed. However, when I realised I was part of her social network and not actually engaging in it I changed my ways, I would come home and actually ask her how her day has been. I found this not only strengthened our relationship and improved her mood, but also helped me decompress after a day at work and understand how she was feeling.
It is well known that loneliness is a contributing factor to Dementia, but research also has shown it increases the bodies cortisol levels, this is the bodies stress hormone, leading to risks of Depression (Schafer D et al, 2020).
Diet
What we eat matters, as explained here in this great quote from a Harvard study shows -
“A dietary pattern characterised by a high intake of fruit, vegetables, whole grain, fish, olive oil, low-fat dairy and antioxidants and low intakes of animal foods was apparently associated with a decreased risk of Depression. A dietary pattern characterised by a high consumption of red and/or processed meat, refined grains, sweets, high-fat dairy products, butter, potatoes and high-fat gravy, and low intakes of fruits and vegetables is associated with an increased risk of Depression.”
Dietary patterns and depression risk: A meta-analysis. Psychiatry Research, July 2017.
My Aunt’s diet when she came to live with me was not great, like a lot of people living with Dementia she had/has a big sweet tooth. We were able to make big changes over a long period of time. Now she has difficulty with swallowing and is on thickened fluid and pureed foods, but we still have our five a day, only now it’s within a smoothie.
My Aunt, like everyone else still has her good days and bad days, her up’s and down’s. But now we have much greater control over it, the bad days for Depression are further apart. Today, we have private carers who don’t come from a standard agency, who I personally trained, and I’m happy to say they are able to give my Aunt the support she needs on a daily basis.
As a carer, family member and health professional, I can safely say Dementia and Depression are not easy to pick apart. From my experience I can see that living with Dementia when also having to deal with Depression makes life a lot harder.
If you have any questions or think one of your patients or loved ones might have Dementia or Depression, feel free to contact us at Sunday Care Therapy.
We believe in understanding what is important to you and working with you to make it happen.
Are you a carer? Do you live in Hackney? Are you aware of Carers First? This is a Charity working with unpaid carers to provide practical information and advice. Sunday Care Therapy are delighted to say we will be providing free training to carers via Carers First, online.
Is there any area you feel you would like you would need extra training on, then get in touch and we can see how we can help.
Are you a Care Assistant? Feel like you need a new exciting challenge, then come be part of the Sunday Care Therapy team, we are always looking at recruiting to our tribe. Work with us to turn care into a career.
Do you or any loved ones need care? Contact us for a free OT assessment, let us work with you on what is important to you.
References:
Andrea Zaccaro, Andrea Piarulli, Marco Laurino, Erika Garbella, Danilo Menicucci, Bruno Neri, Angelo Gemignani
Front Hum Neurosci. 2018; 12: 353. Published online 2018 Sep 7. doi: 10.3389/fnhum.2018.00353
Catalan-Matamoros, D., Gomez-Conesa, A., Stubbs, B., & Vancampfort, D. (2016). Exercise improves depressive symptoms in older adults: An umbrella review of systematic reviews and meta-analyses. Psychiatry Research, 244(2016), 202–209. http://doi.org/10.1016/j.psychres.2016.07.028
David Kitching. Depression in dementia. Published online 2015 Dec 1. doi: 10.18773/austprescr.2015.071
Dietary patterns and depression risk: A meta-analysis. Psychiatry Research, July 2017.
Dudas R, et al, 2018 https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003944.pub2/information/en#whatsNew
Lam, F. M., Huang, M. Z., Liao, L. R., Chung, R. C., Kwok, T. C., & Pang, M. Y. (2018). Physical exercise improves strength, balance, mobility, and endurance in people with cognitive impairment and dementia: a systematic review. Journal of Physiotherapy, 64(1), 4–15. http://doi.org/10.1016/j.jphys.2017.12.001
Serafini G, et al, (2016) Suicide Risk in Alzheimer’s Disease : A Systemic Review. Alzheimer’s Res, 13(10): 1083-99
David R. Schaefer , Thao Ha , Douglas A. Granger
Loneliness and cortisol are associated with social network regulation
Pages 269-281 | Received 15 Aug 2019, Published online: 03 Jan 2020
