Pseudodementia: Symptoms, Causes, & Treatments

What Is Pseudodementia?

Patients with pseudodementia display cognitive deficits or memory issues with the primary reason being an underlying psychiatric disorder, often cited as depression. The distinction between dementia, pseudodementia, and depression is difficult to make because of overlap in symptoms. Some psychiatrists and other mental health practitioners are uncomfortable using the term pseudodementia at all because it reflects a description rather than a diagnosis.

Researchers have found depressive pseudodementia in 0.6% of people aged 65 or older. Higher rates may be found in patients who present for assessment of cognitive decline.² The major areas of cognitive functioning that are negatively impacted by pseudodementia include executive function, speech and language, and memory.

Where Did the Term Pseudodementia Come From?

Pseudodementia became popularized by psychiatrist Leslie Kiloh in 1961. At that time, he authored a paper titled “Pseudo-dementia,” which highlighted vignettes focused on 10 patients with depressive features. At the time, dementia was perceived to be irreversible, but his work demonstrated that it was potentially possible to reverse cognitive impairments attributed to psychiatric disorders, such as depression and schizophrenia.^3,4

Pseudodementia vs. Dementia

There are several parameters to help distinguish between pseudodementia and dementia, including the fact that pseudodementia and depression are potentially reversible, while dementia is harder to treat, depending on the progression and stage.

Other parameters to help distinguish between pseudodementia and dementia include:

• How the dementia presents: People with depression may complain about having memory problems and appear upset, but they will usually exhibit no deficits on objective neuropsychological tests of memory. People with dementia often deny having problems with memory or minimize their importance, but still display impairment on neuropsychological tests.⁵
• Awareness of the memory problems: People who have dementia are unaware of memory problems or deny them but may score poorly on cognitive testing. Patients with depression and cognitive impairments do better on cognitive testing and are generally aware of problems with memory.
• Geriatric Depression Scale test results: Tests like the self-reported Geriatric Depression Scale (GDS) can be a valuable tool to distinguish between dementia and PDEM. Results from the GDS are combined with information about a person’s history and current functioning to help with the diagnosis. For example, people with pseudodementia typically do not have a history of mood swings and are likely to score high on the GDS (high = more depressed). People with dementia show a range of emotions.⁶
• Loss of all memories vs. more recent memories: Depression can cause memory loss. In fact, one study depicts depressive PDEM patients had equal loss for recent and remote events, were characterized by patchy or specific memory loss, had intact attention and concentration, and gave frequent “don’t know” answers.⁷
• Behavioral changes: Because pseudodementia is often linked with depression, people with this condition experience depressive behavioral symptoms, including anhedonia, depressed mood, and fatigue. This is not always the case with dementia.
• Response to treatment: People with pseudodementia often respond to treatment. For example, in depression-related cases, improving the depression often reduces or resolves the dementia symptoms.

Pseudodementia Symptoms

Symptoms of pseudodementia include depressed mood, memory impairment, and difficulty concentrating. One thing that distinguishes pseudodementia patients from dementia patients is that those with pseudodementia can be aware of cognitive impairments they are experiencing. People with dementia, however, do not always recognize symptoms or deny the degree of their deficits. Ultimately, this insight can enhance feelings of depression and anxiety.

Patients with pseudodementia may or may not have a history of depressive or vegetative symptoms. They tend to have flat affect, and give up easily when mental status is examined, or say they cannot perform a task without trying.¹⁰

Common symptoms found in people with PDEM include:

• Depressed mood
• Feelings of helplessness and hopelessness
• Problems with speech and language, including slowness in speech or trouble retrieving words
• Memory impairment
• Problems with the ability to concentrate or focus attention
• Difficulty with organizing, making decisions, or planning tasks
• Low energy levels
• Social isolation
• Loss of appetite or overeating
• Reduced psychomotor function (slower thought processes, decreased physical movement, muted physical and emotional reactions, decreased ability to express emotions)

What Causes Pseudodementia?

Depression is one of the primary mood disorders related to pseudodementia because cognitive impairment can stem from depression. However, experts point out the complexity of determining a final diagnosis in patients with a mixture of depression and cognitive deficits. As such, these experts will sometimes refer to a patient as having an organic disorder or a functional impairment, but most of the patients have components of both.⁸

Causes of pseudodementia can include:⁹

1. Increased stress and depression alter the hypothalamic-pituitary axis, causing cognitive impairment
2. Psychosocial and environmental factors, including abuse (mental and physical), poor social support, negative life events, and substance misuse
3. Issues in neurological pathways involving a part of the brain called the amygdala and its association with the frontal and temporal lobes
4. Neuroendocrine factors, with the degeneration of neurons in the hippocampus leading to cognitive impairment
5. Genetic factors, with repeats in chromosome 9: (i.e., C9ORF72) exhibited in patients diagnosed with depressive cognitive disorders

Complications of Pseudodementia

Pseudodementia is often misunderstood, and it can be easily misdiagnosed, causing excess difficulty for individuals, their loved ones, and their healthcare providers. Without proper treatment, executive functioning may become significantly impaired. In addition, someone with pseudodementia may experience issues with work, relationships, and keeping up with daily activities.

Long-term complications may include:

• Persistent depression
• Disorientation
• Memory loss
• Loss or reduction of autonomy
• Weakened cognitive capacities
• Speech and language function deficits

How Is Pseudodementia Diagnosed?

Pseudodementia is not a diagnosis, but a description of symptoms. Complicating factors in terms of correctly “diagnosing” a patient include the fact that the aging process can negatively impact memory, cognition, and brain function. Depression can occur simultaneously with dementia, but pseudodementia does not cause impairment of function in the brain like dementia does.

Formal testing shows that depressed patients perform better on declarative memory tests than genuinely demented patients, but this difference may be difficult to determine. Instruments such as the Geriatric Depression Scale may also be useful in diagnosing depression in elderly individuals.¹¹

Brain scans can detect evidence of dementia in the brain, as well as a test called the Cornell Scale for Depression in Dementia, which involves interviews with family members, friends, caregivers, and the person being assessed. Evaluators are looking for differences in the reports given by the patient compared with that of the observers. These discrepancies can indicate evidence of both depression and dementia in those being evaluated.

Pseudodementia Treatment

The treatment goal for alleviating pseudodementia is to identify and treat the underlying cause of its symptoms. Symptoms relating to pseudodementia tend to improve after successful treatment for depression, including medication, psychotherapy, or some combinations of the two. However, in some cases, the cognitive deficits may not improve as quickly as the depression.

Therapy

The two most common types of therapy for pseudodementia are interpersonal therapy and cognitive behavioral therapy (CBT). Caregivers should participate in therapy with patients who have memory and cognitive deficits. That way, their observations can be shared with the mental health professional who can incorporate this information into a treatment plan. Family members and caregivers’ understanding of pseudodementia and effective ways to intervene, support, and relate, is a key component to successful treatment.

• Interpersonal therapy focuses on the patient’s relationships with family, friends, and others. It also explores how patients see themselves.
• Cognitive behavioral therapy helps patients become more attentive to negative thinking patterns, teaching them to alter behaviors that are problematic. In addition, therapists teach patients and caregivers coping strategies and techniques to produce a more positive outcome.
• Reminiscence therapy may be effective in helping those struggling with memory impairment. It helps clients use all of their senses to recall memories from their past.

If you’re trying to find the right therapist, consider using an online therapist directory that allows you to search for a licensed, board-certified therapist who has expertise in CBT or interpersonal therapy, as well as experience working with patients with depression and dementia.

Medication

The most commonly used depression medication includes a class of antidepressants referred to as selective serotonin reuptake inhibitors (SSRI). These are generally the first line of treatment for depression in dementia.⁹ Examples of SSRIs include fluoxetine (Prozac), citalopram (Cipramil), and escitalopram (Cipralex).

Electroconvulsive Therapy (ECT)

ECT is a medical treatment that entails briefly stimulating the brain under general anesthesia. It may be recommended as an alternative approach for treatment-resistant depression. Some research shows that ECT can resolve symptoms of pseudodementia. One study found that long-term cognitive improvements were found in eight depressed individuals who underwent ECT treatment.¹²

Can Pseudodementia Be Prevented?

At this point, it is unknown if pseudodementia can be prevented. However, early detection can be key. Recognizing and treating the early symptoms of depression in older people is important to avoid the progression of pseudodementia. In most cases, antidepressants will improve one’s cognitive function, which may reduce or prevent pseudodementia from evolving.

Final Thoughts on Pseudodementia

Because it can be challenging to differentiate between pseudodementia and a mood disorder, patients need to be carefully screened. If it’s determined that a patient has pseudodementia, the prognosis is good in the sense that treatment options are available and it can be reversible when the underlying trigger is treated. Seniors may be more vulnerable because mood disorders are more likely to appear in aging brains.

Ultimately, the love and support from family, friends, and caregivers is an invaluable tool for people with PDEM, and the recovery process starts with finding a qualified mental health professional.