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 S/he has withdrawn from social contacts which she previously enjoyed, spends the day playing solitaire on the computer or watching TV without attending to the show.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 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.

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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. (Picture from www.nia.nih.gov/health/mourning-death-spouse)

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 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.
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Then What Causes These “Psychiatric” Symptoms?
See the next section for this writer’s view of what underlies the “seeming” symptoms of depression,
anxiety and even psychosis many patients with Mild and Major Neurocogntive Disorders display. It is important to understand what is likely at play here, because how you intervene depends on this. For lonely, bored people you don’t give them antidepressants or psychotherapy, because that won’t cure loneliness or boredom, although it might make them more compliant. (Picture from nia.nih.gov)

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