Mad to Tears

Anger as a Sign of Depression in Dementia 

Photo by Sangjan Whansueng on Unsplash


*Resident names and any identifying details have been changed for privacy.

February 05, 2021

She had a sharp tongue, and she wasn’t one to hold it. Typical of a textbook "diamond" on Teepa Snow's GEMS Model, Ingrid’s acerbic remarks could cut deep and sting. Ingrid could whip up her league of ladies in sixty seconds flat, and aim them at any of the residents they viewed as weak or less-than. Those who seemed more impaired were favorite targets.
Ingrid was mad that she had to be in "a place like this", with "people like this" – and she made sure that everyone knew it. I daresay that very few people ever left an encounter with Ingrid under the impression that she was depressed.
Anxiety, sure. You could see a bit of that in her from time to time. "Mean", “sarcastic”, “condescending‘, "angry", "resentful"... These were the words much more likely to come to mind.
The wonderful staff loved her anyway - although they didn’t appreciate the way she treated their other beloved residents. Protecting them from her outbursts and caustic remarks was a daily struggle. Eventually, we realized that Ingrid’s angry behavior was a symptom of a deep depression. Antidepressant medication didn’t change her personality – she was still a sharp and sassy New York firecracker – but the hostile undercurrent was gone. Proper treatment made a world of difference for Ingrid – and for everyone around her.

What is Anger?


Anger has its place and purpose. It gives us strength we need to right wrongs. However, anger is extensively used – and arguably misused, in many cases – by all of us human beings for a number of reasons. 

Anger is a Shield for Painful Feelings


Anger is frequently used to cover other feelings that may be more painful, frightening, or absolutely unacceptable to us personally, than the anger itself.

Fear
Guilt
Grief
Shame
Sadness
Vulnerability
Embarrassment
Out of control 

Anger is a Symptom of Depression

Anger is a prominent feature in depression, although there is some confusion about this in the general population and many people don’t realize it. While anger or irritability is listed as a symptom of depression for children, teens, and seniors, it is missing from the list of symptoms for adults. Many experts have questioned this omission, and many research studies and scientists do acknowledge that anger is highly correlated with depression. There are many stories of individuals who have suffered from anger for years before being diagnosed with depression and properly treated.  

Anger Attacks in People with Depression


In one study on the subject, anger attacks – sudden, intense bursts of anger – were recognized in 30-40% of patients with depression. When those patients were treated with antidepressant medication, the anger attacks disappeared in up to 71%.

Anger is a Stage of Grief

Anger is, in fact, an entire stage of grief. Grief is the process from which humans heal from loss. Grief can be triggered not only by the death of a loved one, but also by other big changes and losses throughout life. Consider the losses that many of our people with dementia are experiencing.

- Separation from or loss of familiar people or places (either literally, or as a result of failing to recognize them, due changes in the brain)
- Loss of independence
- Loss of abilities
- Loss of sense of self
- Loss of cognition
- Loss of communication skills

Add these to the losses life throws any of us – especially as we age, and tend to suffer disproportionate losses of friends, family members, health and more. It's easy to see where people with dementia may have a lot of losses to grieve.

Another of the five stages of grief is depression, so things begin to get quite tangled up in the realm of grief, anger, depression and dementia.

It’s not always easy or clear how to support someone with dementia as they grieve – but if we can figure it out, we can have an enormous impact on their life. 

Symptoms of Depression May Present Atypically in Dementia

Johns Hopkins Medicine points out that, in some instances, people with dementia may not present with typical symptoms of depression. In fact, in some cases, irritability or agitation may be the only sign. In general, they note, when a person with dementia has depression, there tends to be less decline in concentration, indecisiveness, sleep disturbance and feelings of worthlessness or guilt than observed in the general population. Instead, people with dementia tend to have a higher incidence of delusion, hallucination, slowed or agitated body movements, and fatigue or loss of energy.

In addition to irritability or anger, common symptoms of depression in dementia may include: 

- Anxiety, worrying
- Rumination (repetitive negative or hopeless thoughts)
- Sadness
- Tearfulness
- Restlessness
- Agitated movements (such as pulling on hair or clothing, wringing hands together)
- Abnormally slow speech or movements
- Frequent complaints about multiple types of physical discomfort
- Loss of interest in usual activities
- Appetite loss
- Weight loss
- Lack of energy
- Mood may be routinely worse at a certain time of day
- Difficulty falling or staying asleep
- Expresses feeling life is not worth living, or talks about suicide
- Poor self-esteem, feels like a failure
- Tendency to speak negatively about self or blame self for problems
- Tends to expect the worst, pessimistic
- Mood-congruent delusions: delusions of poverty, illness, loss or other negative events worsen as mood declines


Rumination 


Rumination – repetitive negative thinking about the past, in a brooding or hopeless manner – is both a symptom of depression, and a contributor. Those who ruminate are about four times as likely to develop depression than those who don’t.

Furthermore, repetitive negative thinking has been linked to an increased risk of dementia, so this may be yet another thread in a tangled mess of cause and effect in dementia and depression.

Repetitive negative thinking can also include worry and anxiety, which tend to be more future-oriented, but are also tied to both depression and dementia.

Distraction and prayer can be effective in reducing rumination. It can also be helpful to make a plan about how to improve the situation. While making a plan will be a challenge for many individuals with dementia, we can assist them, or if appropriate give them materials to work with.  

A former travel-guide who lived in our memory care center frequently lamented the lack of meaningful activities. We worked very hard to ensure she had lots of activities that were meaningful and interesting for her specifically. She seemed to thoroughly enjoy them. She would often spend literally all day engaged in activities. The moment that there wasn’t something specific happening, her old refrain began again: there’s never anything to do here!
She would get quite stuck in the negative repetitive thought loop, and would immediately seem very depressed.
We started asking her to help plan a day trip for the residents, recognizing her identity and unique skills in this area. We provided plenty of travel brochures, and would ask her opinion about various details and considerations.
I don’t believe her trip ever developed enough to come to fruition, but sharing her expertise helped her feel valued, and planning for the future helped get her mind into a different state, even if only for the time being.
She was still prone to ruminating on the topic, but planning a trip would help her break the cycle and feel better. It also gave staff a way to connect with her on a positive level, rather than becoming stuck in trying to point out all she had been busy doing (which never helped) or empathizing with her (which tended to reinforce her negative feelings in this case). The relationships she developed with staff were very important to her, so having a way to connect was essential. 

The Prevalence of Depression in Dementia

Depression is much more prevalent in people with dementia than in those without it. Depression occurs in an estimated 7-35% of the general older adult population, while 15-50% of those with dementia also live with depression.

The link between depression and dementia doesn’t end there. Older adults with depression are 70-80% more likely to develop dementia later in life than those without depression!

Researchers have known for a long time that dementia and depression go hand in hand, although they have yet to determine whether depression is an early sign of dementia, or if they are two separate conditions with similar causes. They have identified that, while people with any type of dementia have a high prevalence of depression, those with vascular or mixed dementia tend to have a greater tendency towards depression than those with Alzheimer’s disease. The incidence is higher yet – over 40% – in people with Parkinson’s or Huntington’s dementia.

These researchers emphasize the need for early and accurate screening and assessment to identify and treat depression.  

The Cornell Scale for Depression in Dementia

The Cornell Scale for Depression in Dementia has been shown in numerous studies to be very effective at screening for depression in seniors with dementia.

In contrast, the commonly used Geriatric Depression Scale (GDS) has been frequently found to miss depression in many elders with dementia – although it is effective in the non-dementia population. Scientists hypothesize that the GDS loses accuracy because patients are often unaware of, or can't recall, pertinent information. The Cornell Scale, on the other hand, incorporates input from caregivers. It has proven to be a very reliable tool for both identifying and ruling out depression in older adults with dementia.

The Cornell Scale lists 19 possible signs of depression, each of which can be given from 0-2 points. No points are given for any sign that is absent, unable to be evaluated, or that results from a different cause. If the symptom is mild or intermittent it receives one point, and severe symptoms receive two.

One of the potential symptoms on the Cornell scale is “Irritability (easily annoyed or short-tempered)”. If it is the only presenting symptom, the final score will indicate that depression is probably not at the root of the problem.

Depending on how many symptoms are present, and the severity of each, the final score may range from 0-38. A higher score indicates a greater likelihood that the person is experiencing depression. This information should be completed by people who are very familiar with the person’s daily activities. It encompasses information from around the clock, so if multiple caregiving shifts are involved, they should communicate their observations for completeness and accuracy.

When the Cornell scale is completed, if there is a significant score, it should be provided to the doctor. The doctor can complete a full assessment and determine the next course of action or treatment.  

Treatment of Depression in Dementia


According to the experts, the best treatment results for depression in dementia are usually achieved through a combination of antidepressant medication along with non-drug strategies. Obviously, the doctor should handle this portion. Just be sure to keep communication open regarding how the person is doing. Don’t be too quick to dismiss irritability and other potential signs of depression as a person being “just like that” or it being “just the dementia”.

Start with non-drug treatment options – in some cases, they may be all that is required, however, be sure to talk with the doctor soon if symptoms persist. Early diagnosis and treatment can not only improve quality of life sooner, it can also prevent debilitating complications that can easily occur if left untreated. Continued weight loss, agitated behavior or withdrawal from activities of interest, for example, can ignite a chain of events that can be hard to bounce back from. Medications, falls, hospitalizations, pressure ulcers, behavioral crises and functional decline are lurking around every corner. As soon as the balance is upset any of these can ignite an avalanche of interrelated problems, causes and effects.

Due to cognitive impairments, many of the leading non-drug interventions, such as counseling, cognitive behavioral therapy or meditation, may not work for many people living with dementia. However, they can be effective for some, especially in the earlier stages of dementia, so don’t automatically count them out! Look for ways to make it work!

Other non-pharmaceutical interventions for depression, which may be beneficial for people with dementia, include: 


Promoting healthy sleep patterns, routine & structure, such as getting up at the same time each day, developing a relaxing bedtime routine, and cutting out caffeine in the evening
Exercise
Fresh outdoor air
Sunshine or “happy light” exposure
Indoor gardening
Plant or garden exposure
Horticulture therapy
Spiritual connection or spiritual healing
Music therapy
Art therapy
Animal therapy / pet ownership
Touch / massage / hand massage
Snoezelen multi-sensory environments
Helping the person be and feel needed, useful and productive.
Supporting opportunities for meaningful activities.


Dementia: Rediscovering Moments of Joy through Activities with Teepa Snow

Anger, Depression and Dementia


Anger and depression are often closely connected, and there is a very high correlation between dementia and depression.

Anger is a prominent feature in depression, appearing as persistent irritability in some cases, or sudden, intense “anger attacks” in others. Anger can dominate other symptoms to the point where the thought of depression may never occur to onlookers, or even to healthcare professionals.

Anger is sometimes considered a “behavioral symptom of dementia”, as though nothing but the dementia is behind it. There are many potential causes of anger, including grief, unresolved childhood wounds, reluctance to feel other emotions, and depression. Certainly, dementia can also affect, complicate and, sometimes, cause anger, but we should never write it off as “just the dementia” without looking for other contributing factors. 

Key Sources

Johns Hopkins Medicine Geriatric Workforce Enhancement Program: Depression in Patient with Dementia
Depression in dementia 


Have you had experiences with depression looking like anger?

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