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Depression and Pseudo-Dementia in the Long-Term Care Population

Published August 12, 2008 1:30 PM by Brian Garavaglia

What interests me is how often stereotypes dedicate care. In society, individuals still assume older adults should be depressed and that it is part of normal aging. Furthermore, in long-term care this stereotype is even further consolidated. It is often assumed that older adults in long-term care settings, even more so than their same age counterparts in mainstream society, should be depressed, especially due to their presence in a long-term care setting.  It becomes an interesting phenomenon, where behaviors that are abnormal, which depression definitely is, now become "normalized" for long-term care residents because of their age and the social context that they live in. 

Therefore, it is important to address the issue of depression in long-term care settings. Furthermore, it is important to address how many individuals with depression also get misdiagnosed with dementia, a condition that is called pseudo-dementia. In the upcoming paragraphs I will briefly discuss this problematic issue that is often found in long-term care residents. Moreover, I will discuss how this problem can be addressed by changing our stereotypic views of older adults in long-term care settings. 

The elderly in long-term care often face two stereotypic misconceptions:  It is normal to be old and depressed and it is normal to be old and cognitively impaired. Therefore when an older adult is found to be depressed or to be impaired on a cognitive level, this behavior has often become "normalized" in long-term care settings. Furthermore, it is often falsely assumed that both conditions are intractable. Yet, there are many instances when cognitive impairment that is being experienced by older adults can be improved and even eliminated. One of these circumstances happens when elderly individuals become depressed.  When individuals become depressed they will often have memory issues. When younger adults become depressed and have memory problems it often becomes a symptom of their depression. However, when many older adults become depressed and develop memory issues, especially in long-term care settings, the attribution that is often made is the person has an inevitable level of dementia. 

Depression among older adults in long-term care is quite prevalent. Furthermore, it often goes untreated and unnoticed.  Frequently, one of the characteristic symptoms of depression is memory impairment. As stated above, when it is manifested by those who are younger it becomes a prominent feature of their depressive illness. However, what about the older adult in the long-term care setting that starts to forget and has other cognitive issues? How can one determine if it is depression or dementia? After all, it is quite commonplace to see dementia among many long-term care older adults? 

What even complicates the issue further is that the elderly pose a complicated clinical profile. Especially in the long-term care environment, the elderly often have a myriad of clinical issues that can complicate the diagnosis of depression and make it very difficult to rule out dementia. However, a diagnosis of dementia often becomes an easier grab bag diagnosis. This is influenced by the stereotypes that we hold about the elderly in general, and the elderly in long-term care in particular, which regards this age group as inevitably destined to be demented to varying levels.     

Another confounding factor is that depression in many older adults is often atypically manifested. The sad affective presentation and loss of pleasure that is found among many with major depressive disorders can actually be masked in different symptoms such as anxiety, behavioral outbursts and the inability to sleep, which coupled with confusion and memory loss, may be taken as the so-called "sundowners" features of those with dementia. The atypical nature of many depressive disorder in older adults, coupled with prevailing cognitive symptoms, often lead many to overlook depression as being the cause of these memory issues. 

Another important issue is that although many long-term care professionals are quite dedicated toward the provision of care, many come to the profession having very little training in this area. Most physicians who work in long-term care were not trained as geriatricians, and often work in long-term care facilities in addition to their other practice. Many nurses have completed much of their training in acute care health care facilities. Also, most social workers, psychologists and psychiatrists have spent most of their training addressing the problems of a more youthful population. 

Therefore, many of these professionals are not as uniquely sensitized toward the special needs of the older adult populations in long-term care as those who have special training in this area. Furthermore, many of these professionals bring stereotypes that they have learned about old age and the elderly to the clinical setting, which in turn fails to allow them to see beyond this misconceptions and leads them toward missing a diagnosis of depression.      

Many fail to understand the overlapping significance between depression and dementia in the older adults.  Therefore it is often assumed that these two disorders exist in exclusivity. However, in reality, depression in older adults can lead to memory disturbances and other cognitive issues that mimic dementia (see diagrams below). Although most forms of dementia cannot be eradicated, pseudo-dementia caused by depression is quite treatable once the underlying depression is lifted.

Therefore, very important in addressing the complicated issue of targeting depression in those elderly is overcoming many of those harmful stereotypes that can make us loss sight of this important underlying problem.  Furthermore, hopefully one will come away without automatically assuming that memory issues found to exist among older adults are not just inevitable consequences of their age or of being a resident in a long-term care environment.  Hopefully, after reading this brief article, the reader and long-term care professional will come away with an increasingly sensitized eye for understanding the implications of depression among elderly in long-term care and how many memory problems may be corrected with the appropriate diagnosis and treatment of depression.     

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About this Blog


    Brian Garavaglia, PhD
    Occupation: Long-term care administrator
    Setting: Sterling Heights, Mich.
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