Written by Jeffrey Cummings, MD, ScD, AFA Medical, Scientific, and Memory Screening Advisory Board member discusses depression, sleep problems, and Alzheimer’s disease.
Across neurological diseases, depression has the greatest impact on quality of life in patients, said Dr. Cummings. “When your loved one is depressed, you feel sad, you feel guilty, you feel like you’re doing something wrong and that’s why they’re sad. Linking those changes to Alzheimer’s disease is often not the first intuitive step that a caregiver takes.”
An estimated 40 percent of people with Alzheimer’s and other dementias experience some level of depression. In fact, depression and sleep problems are two major behavioral and psychological symptoms of dementia and Alzheimer’s disease.
Depression causes, symptoms
Cummings says the causes of depression in those living with dementia or Alzheimer’s disease are unknown but are likely multifactorial. “We know many of the chemical transmitter systems that are implicated in depression are also implicated in Alzheimer’s disease, so there’s very likely a biological contribution—at the same time the patients are losing their memory, they are losing their function. They are variably aware of that and certainly those who are aware are likely to have reactive depression as part of their illness.”
“Depression may not be crying. It might be sleep disturbances, appetite disturbances or irritability as a much more subtle presentation.”
-Jeffrey Cummings, MD, ScD
“I’d also like to make the point that the depression may not be crying. It might be sleep disturbances, appetite disturbances or irritability as a much more subtle presentation. A good doctor is going to ask these questions to try to understand more about the mood state because it may not be as obvious as we currently think of depression.”
Signs of depression
Listen to what they are saying. “There’s often content if someone is aware of their depression,” Cummings says. They might say they wish they weren’t such a burden or that they want their end to come. “Those are the kind of things that just speak to that depressive content that the patient is experiencing.” Consider also if the person looks sad. “The secondary signs of depression, which are sleep disturbance and appetite disturbance, can be important signs of depression.”
Cummings said to always look for non-pharmaceutical opportunities first, such as strengthening family connections, taking walks and getting more exercise. “We know that these things can benefit and reduce depression.” If those approaches don’t work, anti-depressants can be prescribed.
A common manifestation of a sleep disorder is what is known as sundowning, which occurs as evening approaches. The person is more likely at that time to have a period of agitation that might last for several hours. It’s recurrent and can be extremely distressing. “Once it starts it’s likely to be present for several months or even a year or two, so we often have to resort to drugs that would help control those agitated periods, particularly if there’s any danger of harm for either the caregiver or the patient.
“The important thing about sundowning is that it speaks to the disruption of the circadian, or daily, rhythm. Our daily rhythm of sleep and wake cycles are governed by our brain, and as the brain is affected by Alzheimer’s disease there is a breakdown of that rhythm.”
Reducing noise, directing the person’s attention to a pleasurable activity and closing curtains to minimize shadows can help reduce sundowning agitation.
As for helping your person achieve improved sleep, Cummings recommends:
- Keeping them physically active during the day.
- Maintaining a steady daily rhythm in terms of times to get up, eating each meal and going to bed.
- Limiting their liquids before bedtime.
- Avoiding caffeine at night.
- Relieving their chronic pain with medication before they lie down.
- Not allowing them to use electronic devices before bedtime.
“It’s well worth the payoff given the high cost of sleep disturbances to both the patient and the caregiver. “When the patient is awake the caregiver is bound to be awake. So as the sleep disturbances get more and more common as the disease goes on, you’re also eroding the sleep of the caregiver and making their daytime life much worse.”
AFA Medical, Scientific, and Memory Screening Advisory Board member Jeffrey Cummings, MD, ScD, is the director of the Chambers-Grundy Center for Transformative Neuroscience at the University of Nevada, Las Vegas.
This article is adapted from the AFA Fireside Chat series, Episode 3. View AFA Fireside Chat episodes at www.alzfdn.org/firesidechat.
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