What works best for treating depression and anxiety in dementia?

It's 3 p.m. on a warm, sunny Saturday. For the past 20 years your mother would dress in her finest clothes and walk to her neighbor's house for her weekly bridge game. For the past month, however, she has not been interested in playing bridge. Although she sometimes required prompting (as well as reminders to brush her hair), she usually returned from these games cheerful. Her indifference this month is new.

Your mother received the diagnosis of mild Alzheimer's disease last year. Although visibly frustrated at times, especially when she cannot think of the right word or find her pocketbook, she seemed to enjoy her routine until recently. You now see her crying in the morning. She is no longer sleeping or eating well, and she becomes scared when you leave her for a moment. You wonder whether she might benefit from medications.

Depression and anxiety in dementia

Depression and anxiety symptoms are extremely common in dementia and mild cognitive impairment (MCI). As a result of these symptoms, many people with dementia experience a decrease in their quality of life. Depression and anxiety may lead to disengagement from daily activities, which may further exacerbate memory difficulties. Social withdrawal and discontinuation of cognitively stimulating activities as a result of depression increase the likelihood of nursing home placement.

Do antidepressants work in dementia?

Among older adults living with depression, those with cognitive impairment differ from those without cognitive impairment. Although data on antidepressant use in dementia is ambiguous, much of the current research suggests that antidepressants don't work well in people with dementia (unless they have a pre-existing mental health problem). This could be the result of changes to the brain that occur in dementia. Although many doctors prescribe antidepressants as a first-line treatment, guidelines do not suggest the routine treatment of depression and anxiety with antidepressants in people living with dementia. Even the best-tolerated antidepressants in older adults carry serious risks of falls, fractures, and drug interactions.

A better approach to treatment

Recently, researchers at Weill Cornell Institute of Geriatric Psychiatry in New York studied the effectiveness of a new home-delivered therapy called Problem Adaptation Therapy, or PATH, in participants with depression and dementia or mild cognitive impairment.

In the PATH intervention, therapists meet with the participants in 12 weekly sessions to teach them how to solve problems contributing to sadness, through a personalized approach often involving caregivers. The therapist and patient develop a plan, which includes avoiding negatively charged situations and identifying stimuli that trigger positive emotions, such as scheduling pleasurable activities.

Therapists also help participants develop compensatory strategies, such as the use of calendars and checklists, to bypass functional limitations due to memory impairment. When compared to a control therapy, in which participants received 12 weeks of supportive therapy (teaching them how to express their emotions while providing empathy), participants treated with the PATH approach experienced a greater decrease in depressive symptoms (43%) and disability (93%) at week 12.

Although research on psychosocial interventions is still sparse, this new research is encouraging, as nonmedication treatments are desperately needed. Research is also emerging on psychosocial interventions to decrease anxiety in people with cognitive disorders.

Give new interventions a try

Even though research is still emerging, studies suggest that psychosocial interventions are currently the best and lowest-risk treatments for depression and anxiety in older adults with cognitive impairment. A broad range of supportive approaches for nonmedication treatments exists, and should be used if available as a first-line treatment.

How can caregivers best help?

Scheduling pleasant activities, helping a loved one structure their day in a meaningful way, and problem-solving around issues contributing to distress may all help improve mood and decrease anxiety. In addition, it is important to help your loved one keep their brain sharp by eating a healthy Mediterranean diet, engaging in physical activity, and yes, continuing the weekly bridge games.