Clinical Geriatrics

Case Presentation

Mrs. D is an 85-year-old widowed woman who resides with her granddaughter, Ms. S. Mrs. D was diagnosed with dementia of the Alzheimer’s type 8 months ago and is currently being treated with donepezil 10 mg daily. She also has hypertension, coronary artery disease, and osteoarthritis. Her other medications include losartan 50 mg daily, aspirin 81 mg daily, and acetaminophen 650 mg 3 times daily. Mrs. D receives 4 hours daily of home attendant services 5 days per week. Ms. S moved in with her 6 months ago to help with her care. Mrs. D raised her granddaughter after her mother was sent to prison for drug-related crimes. Ms. S is very devoted to her grandmother, but works long hours as an event planner.

Mrs. D has had a relatively stable course since her dementia was diagnosed, with clear impairments in recent memory, word finding, and difficulty with dressing and preparing meals. She has been accepting help from her home attendant and has been going outside for a daily walk. Mrs. D was able to tolerate being alone after her aide left, and she ate the food prepared for her. Ms. S begins to notice that when she comes home from work, her grandmother is asleep in front of the television, and several times per week she has not eaten her breakfast or dinner. Ms. S leaves notes for the home attendant to place the food out where Mrs. D can find it easily.

Mrs. D is becoming tearful each morning when her granddaughter leaves for work. Ms. S stays later some mornings until the aide arrives but cannot do this very often. She continues to find that her grandmother is not eating meals and encourages Mrs. D to have a snack with her. She also notices that Mrs. D is often awake most of the night, quiet but pacing in the apartment. Mrs. D’s crying spells appear to be increasing, and she often sits by herself in the dark. Ms. S feels terrible and tries hiring an additional aide to help her grandmother.

The new aide is able to get Mrs. D to eat more and takes her to her primary care physician. No new medical problems are identified, and the results of lab tests including a complete blood count, chemistry panel, thyroid profile, vitamin B12, and folate levels are all within normal limits. Mrs. D has lost four pounds since her last appointment 4 months ago. The doctor suggests that Mrs. D take a multivitamin and a nutritional supplement to help her maintain her weight, which has always been on the low end of the ideal range for her height. He also states that she “looks depressed” and suggests a psychiatric evaluation. Ms. S feels desperate to help her grandmother and arranges to take time off from work to attend the psychiatry appointment.

Discussion

Depressive features are relatively common among patients who have dementia.1 Up to 45% of patients with dementia display depressive symptoms that cause distress during the course of their illness.1-3 Depression in a patient with dementia results in an increase in behavioral disturbances, subjective distress, and premature decline in functional status.2 Caregiver burden increases significantly when depressive symptoms occur.