Depression in dementia
Comprehensively assess a patient with dementia who has a depressed mood to exclude differential diagnoses, determine factors contributing to symptoms and assess severity; see Assessing behavioural and psychological symptoms of dementia and Assessing a person with depressive symptoms. The Cornell Scale for Depression in Dementia is a useful tool to assess depression in patients with dementia.
Treat a patient with dementia who has major depression by optimising nonpharmacological interventions (see Principles of treating major depression in adults and young people and Nonpharmacological management of behavioural and psychological symptoms of dementia) and offering psychological therapies (see Psychological therapies for major depression). There is a lack of evidence to support the use of antidepressants for major depression in dementia—a Cochrane review1 found they had limited or no efficacy. Antidepressants are associated with adverse effects (eg dry mouth, dizziness, hyponatraemia) and increase the risk of falls and fractures in older people—see Antidepressant adverse effects. Nevertheless, consider starting an antidepressant for major depression in dementia if the patient has:
- mild to moderate major depression that does not respond to nonpharmacological therapies within 4 to 6 weeks
- moderate major depression and has previously responded well to an antidepressant
- severe major depression.
If possible, use an antidepressant to which the patient has responded—see Antidepressant regimens. Avoid using an antidepressant with significant anticholinergic effects (eg tricyclic antidepressants), which can impair cognition and increase the risk of delirium.
If the patient has not previously taken an antidepressant, citalopram, escitalopram and sertraline are commonly used. In choosing an antidepressant, consider the:
- risk of drug interactions
- risk of QT-interval prolongation
- patient’s comorbidities.
If an antidepressant is appropriate for depression in dementia, use:
1 citalopram 20 mg orally, in the morning; maximum daily dose of 40 mg. For patients older than 65 years, use 10 mg orally, in the morning; maximum daily dose of 20 mg. See below for follow-up and duration of therapy depression in dementia citalopram citalopram citalopram
OR
1 escitalopram 10 mg orally, in the morning; maximum daily dose of 20 mg. For patients older than 65 years, use 5 mg orally, in the morning, maximum daily dose of 10 mg. See below for follow-up and duration of therapy depression in dementia escitalopram escitalopram escitalopram
OR
2 sertraline 50 mg orally, in the morning; maximum daily dose of 200 mg. See below for follow-up and duration of therapy. depression in dementia sertraline sertraline sertraline
Throughout antidepressant therapy, regularly review treatment response and monitor for adverse effects. If an unacceptable adverse effect is experienced, switch to an antidepressant less likely to cause the adverse effect and consider seeking specialist advice.
If, after 2 to 4 weeks of antidepressant therapy:
- the patient fully responds, continue at the same dose for at least 6 months then stop—take additional care when stopping antidepressants in patients with severe dementia because they are more likely to develop depressive symptoms
- the patient partially responds or does not respond, consider and address reasons for poor response—see Key questions to assess nonresponse to an antidepressant for major depression. If there is no explanation for the poor response, increase the dose then review after 2 to 4 weeks of treatment at the higher dose. If depressive symptoms persist at the maximum tolerated dose, consider specialist referral.