Myth vs. Fact: Know the difference between dementia, depression

Allison's father was in his mid-70s when he noticed foul odors he thought were coming from his body. No matter how often he bathed the odors continued. He saw his doctor about the unusual smell and was diagnosed with a psychiatric disorder. Lewy Body disease was relatively unheard of at the time. The correct diagnosis came following visits to a neurologist and testing. Allison's father was suffering from a form of progressive dementia.

Eventually other symptoms surfaced. Her father became easily lost, confused, prone to falling, and later was unable to recognize his family. At times, he experienced tremendous agitation. The most common cause of distortions of reality (psychosis) later in life are due to dementia according to J. Broadway and J. Mintzer's article, "Many Faces of Psychosis in the Elderly," (2007). The second most common cause is depression. The two are often confused.

Psychotic symptoms include hallucinations or delusions. Hallucinations consist of seeing, hearing, smelling, tasting or feeling things without any stimulus to cause the sensation. Delusions are thoughts not based in reality. The American Geriatrics Society's, "Guide to the Management of Psychotic Disorders ..." (April, 2011) describes feeling endangered or suspicious and beliefs about thievery as the most common delusions.

Consistent sadness, and changes in sleep or appetite may be linked to depression rather than symptoms of dementia itself. Diagnosis of dementia is a process. Infections and other medical conditions can cause changes in thoughts or behavior. A primary care doctor may begin with a thorough physical, including lab work, to rule out varying explanations for the symptoms. Side effects from certain medications are sometimes the culprit. There are different rating scales used to distinguish between depression and depression caused by dementia.

The value of both the person and caregivers directly providing good history is very important. Noting when symptoms began, changes in medication, other medical conditions, habits of nutrition, and experience of pain can help to determine the cause of changes in thoughts, mood and behavior.

If changes in behaviors and thoughts are solely due to depression, treating the depression may help alleviate these difficulties as well. If dementia is diagnosed and determined to be the cause of symptoms, antidepressants can still be prescribed, but if symptoms are severe or dangerous, antipsychotic medication may also be added.

Although antipsychotic medication is used to help with psychosis, it comes with its own risks in the elderly. Antipsychotic medication has been linked to a higher incidence of death from heart disease or infections. The Federal Drug Administration issues a black box warning for antipsychotic medication used for elderly people with dementia due to this concern. This puts caregivers and healthcare providers in a difficult spot. It is a time of weighing and balancing quality of life issues against risks.

As an aging population, we can expect an increase in the number of people developing dementia. We have medication temporarily stalling its progression, but nothing that stops or cures it. Dangerous behaviors due to confusion and psychotic thinking can occur causing persons with dementia to wander from their homes, or to strike out at others for no apparent reason.

The Conversation Project and Institute for Healthcare Improvement, developed tools providing a framework for discussing with loved ones with dementia their values and desires at this point in their lives. Ideally, it would be best if we had these conversations well before symptoms are experienced, but according to the Project, although "90 percent of people say that talking with their loved ones about end of life is important," only "27 percent have actually done so." provides a starter kit free of charge, addressing issues of dementia. The kit provides a way to understand the desires and values of family members regarding their care and well being. These types of conversations, including ones with healthcare professionals, help to navigate around issues of medication, and behavioral and supportive treatment options.

Research continues, yet the answers needed to adequately prevent and treat dementia are not at hand. Until resources improve, gathering information and discussing options is the best way to secure the comfort and safety of the person suffering with dementia.

Carolyn Sacco, RN has worked as a nurse in psychiatry since 1985, in inpatient hospital, outpatient clinic, and home settings. Jeffrey Geller, MD. MPH is professor of psychiatry at the University of Massachusetts Medical School. He also treats in- and outpatients.


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