Features of Dementia: Are they Psychiatric?

The most common referrals we get, after memory difficulty, are complaints about “emotional” changes in a patient. We’ve seen thousands of patients who were happy and productive for 80 years and then suddenly, out-of-the-blue, they seem to become depressed. Or, now they are anxious. Or, s/he is doing odd things like believing their children are stealing money (“I saw my son with my check book!”) they now have paranoid delusions. These are referred to as psychiatric features of dementia, but when you study on each patient’s individual situation and look at what “triggers” the problem behavior, or what doesn’t (“She just sits and stares”) you start to wonder if these are really emotional problems at all…

Is it Anxiety–or maybe not?
When a family member describes “anxiety” in dementia patient, we think agitation. The outward signs look similar; i.e., wandering from task-to-task, puttering about in an aimless fashion, picking lint off the rug endlessly, obsessing over bills or medications, etc. Compulsive behaviors are a type of anxiety, but in a dementia patient anxiety is often not the cause. Patients will appear nervous as though they don’t know what to do next, or where they should be–which is absolutely true. This inability to self-manage places the patient in a near-constant state of discomfort, feeling out of place and without direction and this is often expressed in a hyperactive style, asking questions interminably or becoming irritable and–agitated. When the hyperactivity becomes constant this is referred to as akisthesia, but all this has nothing to do with anxiety, instead it is due to dementia. And, yet since it looks like nervous/anxious behavior families ask doctors to treat it with anti-anxiety medications.

In the past, the Valium-type drugs (Serax, Ativan, Xanax, etc.) were commonly used, but aside from addiction risk they induce confusion and increase fall risk in the elderly. And, they work by quelling agitation by dulling a person’s responsiveness to the social and physical environments. This robs a person of their ability to engage in life. A better option is changing the physical and social environment, so the patient can adapt easily and feel comfortable– as a progressing neurocognitive disorder gradually takes away their ability to manage for themselves.

How about Depression–or not?
Another common misinterpretation is the patient is “depressed.” S/he has withdrawn from social contacts which she previously enjoyed, spends the day playing solitaire on the computer or watching TV without attending to the show. She has become quiet, withdrawn and does not initiate conversation. Her affect seems “flat,” and she no longer

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starts new projects or engages in prior hobbies like gardening, painting, crafts, wood working, etc. They seem to lose interest in doing things–and become resistant to any new activity. S/he may sit quietly doing nothing for hours, but will, automatically, carry out a simple routine like getting a sandwich out of the refrigerator when the clock strikes noon. We call these behaviors amotivation, abulia and anhedonia referring to an inability to get started on tasks, engage meaningfully with life or take pleasure from previously enjoyed activities. In a non-cognitively impaired person this would certainly sound like signs and symptoms of classic depression, but this is not true in a mildly cognitively impaired or dementia patient.

Rather then depression, all these symptoms are due to reduced cognitive capacity; e.g., when one can’t retain what they read, see or hear–s/he doesn’t pick up a magazine, or switch the TV channel to more interesting content. So when you bring the patient to the doctor for “depression,” once again, the most common intervention is antidepressant medication. This might provide a little energy, seeming to “boost” mood, but it does nothing to address the actual cause of the problems (amotivation, abulia and anhedonia) due to self-withdrawal from social and physical activities. People no longer initiate social interactions or respond effectively because of worsening cognitive function, and the Prozac-type drugs won’t change this.

Psychosis–or is it?
Finally, we have confusion and in more advanced stages of neurocognitive decline. This can appear as psychotic-like symptoms such as delusions and even hallucinations. But, did your loved one suddenly develop schizophrenia at age 80? No, again this is due to advancing dementia, not sudden-onset psychosis. Rather than a dopamine imbalance, the biggest causal factor is boredom. Consider, you look forward to a snow day that forces you to stay home from work–especially if the kids still go to school! You can read that article, send a long overdue email, try out that recipe out or finish a project you never had time to, before. In other words, you can entertain and engage yourself by self-organizing what you want to do and then carry out the steps and actions to complete these tasks successfully given your free time until the snow is cleared away. You are exercising self-determination and getting things done with efficiency.

In contrast, free time is the enemy of a dementia patient who can no longer self-organize time or plan out the methods and timing to efficiently carry out the steps of an activity. An attempt to do this, often as encouraged by family (“Get out in the garden–you used to love it!” or “Why not make that stew you’re famous for.”) only results in staring, feeling incompetent and upset when you can’t remember if the tomatoes are cooked before the meat in your famous stew. Cripes, you can’t even find the tomatoes any longer in the kitchen! If the patient struggles to find a hoe, can’t figure out how to use it correctly and chops away at the tomatoes, rather then the weeds, are we surprised this activity is no longer enjoyable and is avoided? The person can no longer depend on their internal mental capacity to organize a free day, or even the steps to complete simple project. A dementia patient
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must rely on “external” cues to plan their activities, such as a schedule of events where they can be cued to move from one to the next, that occurs exactly in the same sequence each day. Innovation, exciting new life events and surprises are no longer a dementia patient’s friend! Of course, getting family to recognize and accept this is nearly impossible, as they keep trying to get the patient can to his normal pattern, which causes frustration and upset, even more withdrawal and ultimately agitation. But, this is not psychosis.

If are not Emotionally caused–then what is it?
When a dementia patient is left alone, they retreat into their mind which is increasingly empty and can be a scary place. When you wake up at night and your thoughts start ruminating–are they happy thoughts about the coming day? More often they are are worries, concerns about things you have to do or even regrets over past events all leading to an “anxious” sleepless night. This is how we are wired. Over the millions of years we evolved, the cave woman who woke up to a noise and said to her cave husband “Did you roll the rock in front of the cave door?” or “Did you throw another log on the fire” survived to pass her worry genes down. The cave person who heard something, woke up and said “Oh, look at the lovely stars” got eaten by the saber tooth tiger and never passed her happy-go-lucky genes down to us. We all inherited the worry gene, not the happy gene, as a survival mechanism. Without stimulation, like lying in bed on a sleepless night, worrisome thoughts intrude and make it harder to sleep. So you get up and read a book for a while or engage in mindfulness meditation to distract your thoughts to something more pleasant, so as to fall asleep again. Our internal world is filled with worries, guilt and rumination over what went wrong. We need external stimuli to distract us from this, and get us engaged with the real world outside out heads.

When a dementia patient has no external distracting interesting activity to engage in, or is left to sit alone with no social contact–they retreat into their internal world, which is no longer organized. This can be a chaotic place, disorganized and prone to scary thoughts and fears just like those that impinge on your mind over a sleepless night. You may see labile mood with sudden tearfulness, but more likely the patient gets up and starts puttering aimlessly about, or picking at lint–in an effort to self-distract–and then we’ve got agitation. The human mind seeks stimulation, if there is nothing external to watch, hear or feel then we look internally and start “ruminating” among the chaotic, disorganized feelings and thoughts that occur. Eventually, we start wandering and folding towels over-and-over, or repeatedly cleaning the kitchen. We are driven to seek external stimulation.

So, when a patient shows agitation should we view it as depression, anxiety and/or psychosis and try to treat that with psychiatric drugs? Maybe, we should realize that the absence of meaningful stimulation may be the real source of the agitation in a dementia patient. And, since the patient can’t plan and carry out a self-determined set of fun activities (like you do on your snow day), this needs to be done for him. We might be better off changing the environment to allow a scheduled series of interesting social events and activities to provide external stimulation– since the patient can no longer self-initiate or self-organize their interactions with the external world given his or her increasingly spare, empty, disorganized and often frightening internal world.

This is non-intuitive as one normally does not look for the absence of things as causing a person’s mood changes, instead you look for clear triggers of upset like an argument, or stressors like a financial crisis causing the mood problems. When you see a person sitting quietly for hours staring at a stupid TV infomercial–instead of
depression, consider that it might be due to the lack of any other source of external stimulation available to the patient. This causes boredom and excessive internalization or ruminating thoughts leading to “anxiety.” Realize the person can no longer self-organize activities (despite your entreaties to “Go do something!”) as they no longer can self-stimulate by selecting, planning and carrying out the hobbies/activities that they previously enjoyed.

So, What’s the Alternative to Drugs?
This writer supported the psychiatric approach for 20+ years by referring to and working in many geropsychiatric hospitals, but as the research starting coming out showing the antipsychotics did little for (other than sedate) people and he started looking for alternative treatments.  Basically, it comes down to distracting the patient by providing interesting activities with plenty of social experiences to keep people from drifting into their internal world which (due to dementia) is typically an empty fearful place.  If someone feels “normal” because they know what is expected of them, where they should be, they are not puzzled by the situation they find themselves in, and there is a comfortable routine–then agitation does not occur, and no drugs are needed.

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In Pennsyltucky, where this writer is from, everyone lived in little row houses with a tiny cement porch in York, PA. You know, the ones with the two metal chairs that look like flowers that sort of rock back and forth. Well, when grandma woke up confused every morning, we’d help her dress in her best frock and do up her hair and put her on one of those chairs on the porch. She’d have a cool glass of ice tea next to her, and she’d watch all the people going about their business on Queen Street. Folks would stop and chat about the weather, her attractive appearance, etc. and she could fully comprehend and respond to that conversation. She would not recognize her neighbor of 90 years she grew up next door to, of 90 years, that she grew up next door to, but they chat every morning.
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In short, grandma felt normal, she was not confronted with new fangled tasks she couldn’t figure out. No one pushed her to walk down to the park and meet new people. She’d come in exactly at noon for lunch, watch a repeat of her soap opera and then sit a spell on the porch in the evening watching folks come home from work and school. They always had a minute to stop and chat. She’d be tired at the end of a productive day, where there were no triggers to make her feel confused or out-of-place and thus we saw no agitation. She slept through the night and woke up to begin the routine again.

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In Sum
When a patient shows “psychiatric” signs and symptoms like depression/anxiety and/or psychosis should we treat that with psychiatric drugs? When we see agitation should we turn to sedating drugs? Maybe, instead we should think that these are signs of boredom and insufficient stimulation to a person who mind has become limited in the ability to self-motivate and self-intiate productive behaviors leading to an end goal. Maybe, we should start thinking about increasing external sources of social stimulation and structured, scheduled activities to productively engage that person in the world. To avoid further retreat into an increasingly spare and empty internal world. Just, maybe…
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