Is It the Dementia, or Is It Me?

You feel flat, slow and far away from things you used to love. Some of that may be the disease. Some of it may be depression, and depression is treatable.

Can depression look like dementia, and dementia look like depression?

Yes, both ways. They share a lot of the same signs, which is why it is easy for one to hide behind the other.

Trouble concentrating, slowed thinking, poor sleep, low energy and pulling away from people can all come from depression. They can all come from dementia too. When both are present, people often assume all of it is the dementia, because that is the diagnosis that was named.

That assumption costs people. Depression is common after a dementia diagnosis. A 2021 meta-analysis in the International Journal of Geriatric Psychiatry found depressive symptoms in about 38% of people with mild dementia. And unlike the dementia itself, depression has treatments that work for many people.

What is the difference between apathy and depression?

Apathy is losing the push to start things. Depression is feeling low, hopeless or guilty. You can have one without the other.

Apathy feels like an empty tank. You might still enjoy a visit from your grandchildren once it is happening, but you do not feel the pull to call them or plan it. People often describe it as not caring, without feeling sad about not caring. The same 2021 meta-analysis found apathy in about 54% of people with mild dementia, even more common than depression.

Depression usually comes with a feeling. Sadness, a heavy sense that things will not get better, guilt about being a burden, or losing pleasure in things even when you do them.

Telling them apart matters because they respond to different things. Antidepressants are aimed at depression. They tend not to help apathy, and a 2023 systematic review in Acta Neuropsychiatrica found they can sometimes cause it. If you started an antidepressant and since then feel flatter rather than better, tell your doctor.

How will my doctor tell which it is?

Mostly by asking you, in detail, about how you feel and not only about how you remember. You can help by saying it in your own words.

There is no blood test or scan for depression. Doctors use your account, the account of someone who knows you well, and sometimes a questionnaire. One, the Cornell Scale for Depression in Dementia, was designed for people with memory problems because standard depression questionnaires rely on recall.

Things that help your doctor:

• Describe the feeling, not just the behavior. "I do not do much anymore" could be either. "I feel like a burden and nothing will get better" points toward depression. "I do not feel bad, I just do not get started" points toward apathy.
• Say when it started. Low mood that began around the time of the diagnosis is understandable. Low mood that was there long before it is also worth saying.
• Mention past depression and anything that helped before.
• List every medication, including over-the-counter sleep aids and allergy pills, since several can dull mood and thinking.

Do antidepressants work for depression when you have dementia?

For some people, yes. On average, the trials are less encouraging than people expect, and the side effects are real. Ask what your doctor expects the medicine to do.

The most thorough summary is the 2018 Cochrane review of antidepressants for depression in dementia: 10 placebo-controlled trials with 1,592 people. It found, with high certainty, little or no difference between antidepressants and placebo on depression rating scales after 6 to 13 weeks. But remission, meaning depression lifting enough to no longer count, was probably more likely on antidepressants: 40% compared with about 22% on placebo. People on antidepressants were also more likely to have side effects, including dizziness and dry mouth, and more likely to stop treatment early.

The 2011 HTA-SADD trial in The Lancet tested sertraline (Zoloft) and mirtazapine (Remeron) in 326 people with Alzheimer's disease and depression. Neither did better than placebo at 13 weeks. Side effects were more common on both: 43% on sertraline and 41% on mirtazapine, compared with 26% on placebo.

One important limit: most of these trials enrolled people with established dementia, often older and further along than someone who has just been diagnosed or has mild cognitive impairment. The results may not transfer neatly to you, especially if you have had depression before and an antidepressant helped then.

Questions worth asking if one is offered:

• Is this for depression, or for something else, such as sleep or anxiety?
• What change should I notice, and by when?
• What side effects should I watch for, especially dizziness or falls?
• When will we decide whether it is working, and how would we stop it?

What else helps with depression?

Talking therapy has modest evidence, and so do the ordinary things that depression takes away first: people, movement, and something to do that matters to you.

The 2022 Cochrane review of psychological treatments in dementia and mild cognitive impairment found that therapies based on cognitive behavioral therapy may slightly improve depressive symptoms, quality of life and daily functioning. The effects were small but real, with moderate certainty. A therapist who works with older adults or people with neurological conditions is a good place to start.

Beyond therapy:

• Keep seeing people, even when you do not feel like it. Isolation feeds depression and is one of the easiest things to drift into after a diagnosis.
• Move every day. A walk counts.
• Keep doing something that matters to you. Volunteering, a role in your family, a project, helping someone else.
• Talk to someone else who has the diagnosis. Being understood without explaining is its own kind of help.

When should I get help right away?

If you are having thoughts of not wanting to live, or of harming yourself, call or text 988 now.

Many people have dark thoughts after a diagnosis like this one. That is not a reason to keep them to yourself. Call or text 988, the Suicide and Crisis Lifeline, any time. You do not have to be in immediate danger. If you are in danger right now, call 911.