Depression superimposed on dementia–two hits to the brain!!!

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY

In recent years the link between depression and dementia has been closely looked at.  Many questions await a definitive answer-

—do attacks of major depression predispose to dementia later in life?  (or put in more simpler terms, does depression hurt the brain and kills  neurons leading to cerebral atrophy and dementia?)

—is depression more common in patients with primary dementia such as Alzheimer’s dementia?

—is depression frequently missed or misdiagnosed in  patients with primary dementia ?

—do patients with dementia have depression which is more refractory to medical treatment?

—does depression accelerate the rate of cognitive decline in patients with dementia?

I recently saw a patient who was referred to me to evaluate for dementia. She was 74-years old and her past medical history was significant for hypertension for which she was on anti-hypertensive medications. When the patient saw her primary medical doctor she had volunteered the information that she was having some problems with her memory. She at times forgot the names of her loved ones, one time she had got lost while heading from home to the hospital. Her home aide further added that she had noticed that the patient frequently misplaced objects and then could not recall what she had done with them. At times she forgot to add an essential ingredient to a dish she was preparing. Recent neuropsychological examination was suggestive of a primary dementia.

As I spoke to the patient, I found her to be quite high functioning. She made eye-contact, gave a succulent history and most importantly had insight into what was plaguing her namely her problems with memory. As the interview went on I learnt that she had been depressed for a while. Though she was on anti-depressants, the recent loss of close family members had made her more depressed. She suffered from a loss of appetite and few things in life gave her pleasure.

So where do we go from here? What is the optimum treatment for someone who might have an underlying primary dementia such as Alzhemier’s disease but also has superimposed incompletely treated depression. Most doctors would agree that her depression needs to be treated more agggressively but the questions which arose in my mind were the following:

–should I treat her for dementia now or reassess her after treating her depression more aggressively?

–is the ongoing chronic depression actually predisposing her to memory problems and maybe even dementia?

–what came first—depression or dementia?

–who is the bigger culprit here–depression or dementia?

All questions for whom we still do not have good answers.  The brain can take a hit here and there but depression-dementia is a deadly combo–likely a death blow to the delicate brain. Maybe one day we shall be able to win the battle against these two scourges.