II. Epidemiology

  1. Incidence in Alzheimer's Disease: 20-30%
  2. Often occurs in early Dementia

III. Symptoms

  1. Dementia patients rarely report sadness
  2. Patients often report vague somatic symptoms
  3. Common presenting complaints
    1. Lack of energy
    2. Patient reports "feeling old"
    3. Pessimism
    4. Hopelessness
    5. Anhedonia (lacks pleasure)
    6. Negative attitude
  4. Vegetative Symptoms
    1. Anorexia
    2. Weight loss
    3. Sleep disturbance

IV. Differential Diagnosis

  1. Depression as primary etiology for Delirium
  2. Hypothyroidism
  3. Occult malignancy
  4. Chronic infection
  5. Medications

V. Evaluation

  1. Cornell Depression Scale

VI. Management: Medications

  1. Course
    1. Non-pharmacologic therapy is much more effective in Dementia
    2. Consider stopping medications after 6-12 months
    3. As Dementia progresses, Depression regresses
  2. Tricyclic Antidepressants (Avoid older tricyclics)
    1. Exercise caution with these agents due to Sedation and fall risk
    2. Nortriptyline (Aventyl, Pamelor) 10-75 mg PO qhs
    3. Desipramine (Norpramin) 25-150mg PO qhs
  3. Selective Serotonin Reuptake Inhibitors (SSRI)
    1. Escitalopram (Lexapro)
    2. Fluoxetine (Prozac) 10-40mg qAM
    3. Sertraline (Zoloft) 25-100 mg PO qAM
  4. Other
    1. Venlafaxine (Effexor) 18-50 mg PO bid
    2. Bupropion (Wellbutrin) 25-100 mg PO tid
    3. Mirtazapine (Remeron)
      1. Consider for suppressed appetite

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