Yulin Chu, N.P.

Alzheimer’s disease (AD) and depression associated with AD are two chronic and serious mental illnesses. Alzheimer’s disease is an irreversible, progressive brain disease that affects about 5.1 million Americans (U.S. Department of Health and Human Services [HHS], 2013).  Depression associated with AD, usually called Late life Depression (LLD), refers to late-onset depression occurring in a person over 65 years old. While depression is not a normal part of the aging process, it does occur and should be treated or it can lead to disability and increased mortality (National Alliance for Research in Schizophrenia and Affective Disorders, n. d.) Patients with LLD are much more likely to develop cognitive deficits, vascular dementia, and AD (Barnes et al., 2012).Effectively treating LLD will not only treat depressed mood, but also help slow down AD progression, and maximize the function of patients. However, currently, depression in AD is under-detected and undertreated (Starktein, Mizrahi, & Power, 2008).
 
The reason for delayed recognition and detection of LLD in AD is complex. 

1) The fundamental problem is the substantial overlap of symptoms between LLD and AD.  Common to both disorders are apathy and loss of interest, impaired ability to think and concentrate psychomotor changes, dysphoria, irritability, sleep disturbance, and social withdrawal. The ability to diagnose depression in AD is further compromised by the patients’ lack of insight and poor recollection of symptoms (Starktein, Mizrahi, & Power, 2008). 

2) AD patients with LLD may be less likely to talk about or attempt suicide. Suicidal ideation may not last long and come and go. 

3) As AD progressing, the symptoms of depression in AD are changed. Dysphoria or feeling of sadness is gradually substituted by irritability and apathy, finally by anxiety, agitation, or aggression (Lyketsos, 2012). Insomnia shown in early and middle stages of AD may change to Sun Down Syndrome in the later stage of AD. Therefore, the National Institute of Mental Health established a formal set of guidelines for diagnosing the depression in people with AD. It reduces emphasis on verbal expression and includes irritability and social isolation (AA, 2013).

Most of experts believe that depression in AD is treatable. However, the treatment of depression in AD may be very challenging, because it is connected with AD treatment. 

1) The treatment difficulty of AD affects the treatment of depression.
 
2) Patients with AD are vulnerable to develop atypical medication side effects from the antidepressant. It includes falls, rashes, reduced oral intake, weight loss, constipation, increased confusion, or delirium. In addition, side effects rarely seen in other settings, such as bradycardia and hyponatremia might be more common in the elderly treated with antidepressants (Lyketsos, 2002).
 
3) The LLD is much more likely to develop with cognitive deficit, vascular dementia, and AD (Barnes et al., 2012). Some experts believe that depression is often one of the first symptoms of AD. It has been associated with worse quality of life, greater disability in daily living (ADLs), faster cognitive decline, and relatively higher mortality (Starktein, Mizrahi, & Power, 2008), higher risk of aggression and greater caregivers’ depression and burden.

Many studies indicated that both of depression and AD are either under-treated or inappropriately treated.  Currently, one of the major methods to treat anxiety, agitation, and behavioral problems is using antipsychotics. Wide use of antipsychotics among the elderly not only impaired their cognition but also significantly increases the mortality (Gardette, 2012). Because Medicare does not cover most of the costs for AD supportive services, and it is difficult to get coverage in the private long-term care insurance, many times the elderly with AD ends up in a hospital more frequently than the same aged people without AD.
 
Research suggests that age, genetics, environment, and lifestyles are risk factors for developing AD. Age alone does not confer vulnerability, but physical condition declining, social loneliness, financial stress, poor living environment, infectious diseases, hearing disability, or language barriers and communication deficits can lead to the elderly minority populations being more venerable to develop depression, emotional disturbances, behavioral problems, or total loss of function. After the onset of depression and early AD, these patients face barriers to obtain diagnoses and service (HHS, 2013). It is worse for minority elderly. Older Hispanics have far less health insurance than their non-Hispanic contemporaries. AD symptoms may strike Latinos almost seven years before white Americans. African-Americans aged 55 to 64 years were more than three times as likely to have AD as their European American counterparts (AA, 2004).
 
References

Alzheimer’s Association (7/21/2004). Minorities hardest hit by Alzheimer’s. Alz.org. Retrieved from http://www.alz.org/national/documents/minorities-english.pdf

Alzheimer’s Association (2013). Depression and Alzheimer’s. Alz.org. Retrieved from http://www.alz.org/care/alzheimers-dementia-depression.asp
Barnes, D. E., Yaffe, K., Byers, A. L., McCormick, M., Schaefer, C., Whitmer, R. A. (2012).  Midlife vs. late-life depressive symptoms and risk of dementia – differential effects for Alzheimer disease and vascular dementia.  Archives of General Psychiatry, 69(5), 493-498. Doi: 10.1001/archgenpsychiatry.2011.1481

Gardette V, Lapeyre-Mestre M, Coley N, Cantet C, Montastruc JL, Vellas B, Andrieu S. (2012). Antipsychotic use and mortality risk in community-dwelling Alzheimer’s disease patients: evidence for a role of dementia severity. Current Alzheimer Research, 9(9):1106-16.

Lyketsos, G. G. & Olin, J. (2002). Depression in Alzheimer’s disease: Overview and treatment. Sociaty of Biological Psychiatry, 52, 243-252. Doi: 10.1111/jpm.12035/pdf

Lyketsos, C. G. (2012). Treating Depression in Alzheimer’s Patients.  Memory Disorders Review, Summer Issue; pages: 22-32.

National Alliance for Research in Schizophrenia and Affective Disorders. (n.d.). Late-life depression. Brain & Behavior Research Foundation.   Retrieved from:  http://bbrfoundation.org/userFiles/facts.latelifedep.pdf

Starkstein, S. E., Mizrahi, R., & Power, B. D. (2008). Depression in Alzheimer’s disease: Phenomenology, clinical correlates and treatment. International Review of Psychiatry, 20(4), 382-388.  Doi: 10.1080/09540260802094480

U.S. Department of Health and Human Services. (2013). National plan to address Alzheimer’s disease: 2013 update [Adobe Digital Editions version]. Retrieved from http://aspe.hhs.gov/daltop/napa/NatlPlan2013.pdf