November/December 2009 Issue
Cognitive Camouflage — How Alzheimer’s Can Mask Mental Health Conditions
It’s not unusual for mental conditions, particularly depression and anxiety, to occur in the early stages of Alzheimer’s disease. But accurate diagnosis and treatment can improve cognitive function.
An Alzheimer’s disease (AD) diagnosis is usually greeted as a death sentence—and with good reason. The disease progressively worsens and currently cannot be reversed or even stopped, although it can be slowed in some cases. In 2006, it was the sixth leading cause of death, according to the Centers for Disease Control and Prevention (CDC).
But awareness of AD’s ultimate outcome often blinds people to the fact that, before reaching the end stage, elders with AD can engage in activities they find meaningful and maintain caring and pleasurable relationships. In addition, an AD diagnosis frequently results in the failure to recognize that cognitive problems may have other, often treatable causes. Among these are other mental health condition—especially depression—that are quite common among older adults in the early and midstages of AD. With accurate diagnosis and appropriate treatment, cognitive functioning can improve. The course of AD cannot be reversed, but life can be better—at least for a time.
A progressive disorder, AD can’t be reversed or arrested, but medications are available to slow its progress. It disrupts memory, thought, perception of reality, and behavior to such a degree that eventually it impairs the ability to work, engage in normal adult relationships, participate in ordinary social and leisure activities, carry out basic tasks such as shopping or paying bills, and ultimately manage basic activities of daily living, such as eating, toileting, and dressing.
The early signs—forgetting a recent event, neglecting to pay a bill, not recalling a friend’s name—are often indistinguishable from typical “senior moments.” To the older adults experiencing them, their families and friends, and their healthcare providers, they may seem like minor problems and a normal part of aging. As time passes, however, the cognitive dysfunction worsens, and the disease becomes more obvious and problematic, both for the individuals and those who care about, and increasingly for, them.
The caregiver burden can become tremendous, with mental, physical, and financial consequences. Families and friends who care for older adults with AD are at increased risk for depression, anxiety disorders, and physical illness. Many family caregivers manage to persevere despite the stress, but many burn out and, understandably, place family members in institutions to relieve themselves of the burden.
Mental Health Conditions With AD
Serious symptoms of depression occur in up to 50% of older adults with AD, and major depression occurs in roughly 25% of cases, according to the CDC. Depression is often thought to be an older adult’s reaction due to awareness of progressive decline, and this is probably the case. However, some research suggests that there may be a biological connection between AD and depression.
Anxiety, including generalized nervousness, fear of leaving home, agitation about changes of routine, and suspiciousness—sometimes to paranoia proportions—are also common, occurring in up to 30% of older adults with AD. Anxiety seems easily understandable in older adults who are aware of their diminishing abilities. But it is possible that, like depression, it may be physically, as well as psychologically, linked to AD.
AD can also co-occur with preexisting psychotic conditions. Older adults with schizophrenia, for example, are as likely to develop AD as those without severe mental illness. And elders with schizophrenia are at higher risk for depression, creating the possibility of three co-occurring mental health conditions. Symptoms of these conditions include the following:
• profound sadness;
Such symptoms often have negative consequences for elders with AD and those who care for them. These include the following:
• the subjective distress of the person experiencing such symptoms;
While suicide does not appear to be more prevalent for older adults with AD than other elders, its risk should not be ignored.
Fortunately, treatment of these conditions often results in improved functioning and quality of life for both the older adults with the condition and their family caregivers.
Therefore, a good differential diagnosis is critical but not easy. Symptoms of AD that are not common in depression include forgetting recently learned information, trouble performing once-familiar tasks, problems with remembering words, and impaired judgment, such as not perceiving the need to dress warmly in severe winter weather.
Screening tools can be helpful in distinguishing depression from AD. The Mini-Mental State Examination and the clock test are useful for revealing dementia. Depression scales include Patient Health Questionnaires 2 and 9 and the Geriatric Depression Scale, all of which can be easily administered unless dementia is fairly advanced, in which case interviewing family members and caregivers is essential, though not totally reliable.
Nonpharmacological interventions can be as simple as providing pleasant activities, a normal routine, and exercise. Behavioral interventions and environmental modifications can help reduce anxiety, agitation, and hopelessness. In addition, formal cognitive behavioral therapy can be effective. And providing psychoeducation for caregivers can help them better deal with the elder with AD, which may have a positive impact on the individual’s mood and general frame of mind.
Sleep disturbances are quite common among older adults with AD, especially those with co-occurring depression. Treatment for depression often results in improved sleeping. But there are also specific psychosocial interventions such as sleep restriction, sleep compression, multicomponent cognitive-behavioral therapy, and stimulus control that are quite effective. Promising interventions include muscle relaxation and sleep hygiene education.
Very cautious use of sedative/hypnotics should be considered only when behavioral treatments are not effective.
In addition, individually tailored behavioral management techniques such as antecedent-behavior-consequence interventions, where caregivers recognize the behavior, identify antecedents, and modify their reaction, the physical environment, and/or the older adult’s routine, can be very effective at reducing problem behaviors when practiced with consistency.
Environmental modifications such as changing the visual environment, using mirrors, posting signs, and unlocking doors for a period of time on closed wards can also be effective.
There is also emerging evidence of the effectiveness of aromatherapy and bright light therapy for reducing agitation.
When behaviors are more severe or fail to respond to such nonpharmacological approaches, atypical antipsychotics may be considered. However, due to risks of enervation, clouded thinking and perception, falls, and premature mortality, they should be prescribed with great caution and monitored carefully.
Addressing the Needs of Family Caregivers
The stress borne by caregivers makes them highly vulnerable to depression, anxiety, and physical illness. Many become overburdened, and some burn out. While not all need support, many can benefit from interventions such as psychoeducation, counseling, support groups, and respite. Mary Mittelman, DPH, a research professor at New York University School of Medicine, has conducted research indicating that a combination of individual and family therapy, support groups, and ad hoc counseling for spousal caregivers reduces depression, anxiety, and physical illness in caregivers of older adults with AD and can delay nursing home placement by up to 18 months.
Caregivers’ mental health also may benefit from behavioral management therapy for the elder with AD, as well as from learned coping strategies.
Care and Treatment Settings
For many, paid caregivers who come to the home, such as personal care attendants, home health aides, and case managers, make remaining at home possible. Unfortunately, many of these workers, despite their caring and skill in attending to physical needs, are not skilled in managing what can be troublesome behaviors or in identifying and responding to other mental disorders.
Some elders with AD receive care and have opportunities for activity and social interaction in day programs, including senior centers, social adult day care, and adult medical day care. These programs also function as a kind of respite service for family caregivers who work during the day. Unfortunately, it’s not common in such programs to have staff with expertise in mental conditions such as depression, which, as previously noted, can make life far worse for older adults with AD.
Over the past several decades, there has been an increase in the number of older adults moving to assisted living facilities, many of which have special programs or units for people with advanced dementia. Unfortunately, there is rarely much expertise in co-occurring mental disorders at such facilities.
Finally, of course, a significant number of older adults with AD go to nursing homes. While some of these facilities provide good care for people with co-occurring mental and behavioral conditions, many do not. There are grave concerns about inadequate attention to mental conditions and the overuse of antipsychotic medications, which can induce stupor and hasten death.
• We do not know how to reverse, stop, or even substantially slow AD’s progressive decline.
• AD takes a terrible toll, not only on the older adults who develop the disease but also on their families and friends.
• There are also enormous costs to society, not only for care and treatment but also in lost productivity of both elders with AD and their families.
Unfortunately, health, mental health, and aging services policies in the United States are not adequately responsive to these facts. Fundamental policy changes are needed, including enhanced research to develop and document effective interventions and enhanced translation of research findings into practice. Also critical is enhancing the quality of care in outpatient, home, community, and residential settings, as well as increasing training and education to build a health, mental health, and aging services workforce competent to meet the needs of older adults with co-occurring mental illnesses and their families.
Additional focus needs to be directed toward enhanced family support, expansion of affordable services, expansion of affordable residential alternatives to institutions, and enhanced integration of mental health and long-term care services.
Ultimately, bringing about the kinds of policy changes necessary to meet the needs of older adults with AD will depend on building political will. Unfortunately, we have a long way to go in that direction.
— Michael B. Friedman, LMSW, is chair of the Geriatric Mental Health Alliance of New York.
— Gary J. Kennedy, MD, is director of the division of geriatric psychiatry at Montefiore Medical Center in New York City.
— Kimberly A. Williams, LMSW, is director of the Geriatric Mental Health Alliance of New York.
Fortunately, his physician recognized that Frank was depressed and persuaded him to go into therapy. He found a therapist who understood how to treat an individual with a combination of AD and depression. He involved Frank’s wife in the process and offered suggestions on ways to be helpful to her husband. With the combination of cognitive-behavioral therapy and psychoeducation, Frank’s depression lifted a bit. He was able to retire gracefully with his reputation intact. He rediscovered an old interest in music, and he was able to respond to care and affection from his family long after his capacity to speak had passed. For him, as for most older adults with AD, love was the last memory to die.
AD took its inevitable toll, but overcoming his depression gave Frank some additional time to live as he wanted and helped him prepare emotionally for the gradual decline into a life that he had previously dreaded. It wasn’t easy for Frank or his wife or their daughter, who also helped out. It never is. But their emotional bond carried them through the difficult times.
Frank and his family were fortunate to have a physician who could distinguish between the effects of AD and the effects of depression. Frequently, that’s not the case. It was also fortuitous to locate a therapist who had expertise in the mental health conditions of older adults. Most do not. As the population of older adults explodes over the next 25 years, more elders will have similar problems, but very few will receive the skilled treatment they need.