Pseudodementia (A complete guide)

Pseudodementia

In this article, we will talk about pseudodementia. We will clarify the differences between pseudodementia and dementia, the sign, symptoms and risk factors of pseudodementia, and the treatment options available. We will also talk about the signs and the implications of depression in old age. 

What is pseudodementia?

Pseudodementia (pseudo = “false”; dementia = “disturbed mind”) is a term introduced into psychiatric terminology by Kiloh in 1961 and describes cognitive deficits in depression or other psychiatric illnesses in the elderly.

It can occur in many psychiatric illnesses, but more frequently in mood disorders, and “mimics” a clinical picture of dementia. The cognitive problems experienced in these cases are due to mental disorders, not damage to the central nervous system.

Pseudodementia (A complete guide)

Pseudodementia has two components:

Dementia = a combination of various cognitive symptoms

Pseudo = lack of evidence for a neurodegenerative disorder.

Some mental health professionals argue that this term should not be used in practice, as the prefix “pseudo-” may lead to an incorrect assumption that cognitive impairment is not real.

However, pseudodementia remains an important descriptive sign for the cognitive deficit in major depressive disorder and hope for patients and relatives, due to the reversibility of this disorder.

Pseudodementia vs. Dementia – diagnostic dilemmas

The importance of the distinction between the clinical picture of dementia and functional diseases is essential and has been pointed out since the introduction of the term in 1961. The author also mentions that the term pseudodementia does not try to have any nosological meaning, but should only be used to describe a medical condition.

Dr Kaszniak is Professor of Psychology, Neurology, and Psychiatry highlighted the following clinical reasons that make it difficult to differentiate between pseudodementia and dementia:

  • The cognitive changes in the elderly make it difficult to establish the difference between a cognitive impairment disorder and the normal signs of ageing.  
  • Depression is in many cases accompanied by a cognitive impairment disorder.
  • There is an overlap of symptoms in both disorders, with certain different forms of dementia – from Alzheimer’s disease or Parkinson’s – having symptoms similar to those of depression.
  • Dementia and Depression can coexist.
Pseudodementia (A complete guide)

How can we correctly differentiate dementia from pseudodementia?

Certain types of memory impairment and individual response to these difficulties can make the difference between dementia and pseudodementia.

There are psychometric tests that help this differentiation. Usually, people with dementia have much poorer results on memory and attention tests, such as:

  • MMSE (Mini-Mental State Examination)
  • The Geriatric Depression Scale (GDS), along with information from the patient’s personal history, is also used to differentiate the two disorders. 

Signs, Symptoms and Risk Factors

Cognitive deficits in pseudodementia are grouped into 3 categories: memory, executive functions and language. Some of the signs of cognitive deficits in pseudodementia are: difficulties focusing, performing tasks and making decisions, difficulties remembering places or things, slow processing speed and decreased speech flow.

There may be other symptoms besides the ones mentioned:

  • depressive mood
  • low energy or fatigue
  • insomnia or hypersomnia
  • lack of interest in regular activities
  • loss or increase of appetite
  • suicidal thoughts

Risk factors for pseudodementia are similar to those for depression: female gender, family history of depression, divorce, low socioeconomic status.

In terms of age, depression can occur at any age, but pseudodementia is usually found in middle-aged or elderly people.

Pseudodementia (A complete guide)

Treatment options for pseudodementia

The treatment options for pseudodementia is similar to the treatment options for depression.  In most cases, cognitive function can be fully recovered. Treatment includes psychotherapy, antidepressant medication or a combination of these.

Cognitive behavioural therapy (exploring and modifying thought and behaviour patterns) and interpersonal therapy (exploring how interpersonal relationships contribute to depressive feelings) are two specific treatments that have been shown to be effective in treating both depression and pseudodementia.

Depression in old age – clinical aspects

Depression in old age is currently considered a distinct clinical entity, the clinical picture of depression having many different aspects compared to the clinical picture of depression in young people. The prevalence of depression is 12-45%, with an average of 20%. 

Depression in the elderly is considered by many practitioners to be a normal process and a consequence of ageing. Old age can accentuate and at the same time suppress some symptoms of depression. 

Depressed mood, the main symptom of depression, is masked in the elderly by some signs, such as:  loss of appetite, sleep disorders or fatigue, which are usually not so intense in young people. The elderly present a poorer clinical picture than young patients, denying a number of important symptoms, such as feelings of guilt, suicidal ideation and very often psychotic symptoms.

The full range of symptoms characteristic of major depression is also present in elderly patients. Some of the most common depressive symptoms in the elderly are:  anxiety, somatic symptoms, cognitive impairment, psychomotor agitation, psychotic symptoms.

Often, depression has an insidious onset, so that neither the patient, nor his relatives, nor even the doctor readily recognizes the disease, a feature that is especially true in patients with somatic diseases. In this case, clinicians must obtain information from multiple sources, information to consider when evaluating the clinical picture.

The depressive mood is the main symptom of depression at any age. However, this symptom may be absent in many seniors. Elderly depressed people usually respond emotionally to positive events, and their affectivity fluctuates widely and more frequently than in young patients.

Deep anhedonia (inability to enjoy) is rare because the elderly usually maintain their emotional reactivity to positive events. The pleasure of the company of younger family members, grandchildren or great-grandchildren is rarely diminished in the elderly.

Fatigue or lack of energy is a common symptom, being present in most elderly patients. Usually, this symptom is attributed to old age and is treated accordingly, erroneously, with vitamins (4).

Sleep in depressed patients is superficial, fragmented, shorter than normal, which gives them the impression that they have not slept. The elderly need fewer hours of sleep and often wake up during the night due to physiological needs (eg, nocturia).

Poor posture, appetite disorders or weight loss can be early indicators of depression, but they can also be present in dementia. Cognitive changes in depressed elderly patients should never be omitted, as they may indicate a “pseudodementia”, sometimes secondary to depression.

Pseudodementia (A complete guide)

Psychotic symptoms in the elderly are represented by delusional depressive ideas, uselessness or guilt. Hallucinations have also been described, the most common being the auditory and visceral ones (when the patient has the impression that the internal organs are rotated, are affected by some diseases or even missing).

Positive diagnosis

Depression in the elderly is often undiagnosed, as in some elderly patients feelings of sadness and depression are highlighted only by self-assessment scales. 

The positive diagnosis of depression in the elderly includes several steps of the psychiatric examination, and it is based on the positive elements, and not by exclusion.

Hereditary collateral history of affective disorders in patients who have their first episode of depression at an advanced age is often negative, unlike younger patients. If they do exist, they are very important, because the family history of first-degree relatives increases the likelihood of developing depression.

Regarding the personal pathological antecedents, special importance in the evaluation of the elderly patient has:

  • the duration of the current episode of depression (at least two weeks);
  • the number and intensity of previous depressive episodes;
  • evaluation of the history of drug or alcohol abuse;
  • the initial response to antidepressant therapy in previous episodes (7,9).

Recognizing depression in the elderly requires experience from the doctor. Differentiating the somatic symptoms of depression from the symptoms of somatic diseases can be difficult and this is a real test for the psychiatrist, as all these symptoms can occur in a single patient, requiring a physical examination and paraclinical investigations to identify a possible organic cause of depression.

Physical examination especially focused on neurological examination, allows the identification of organic causes of depression or the identification of contraindications for certain classes of antidepressant drugs. 

Little discussed in the literature, but frequently encountered by clinicians in psychiatric practice are behavioural disorders: food refusal, urination and defecation outside the toilet, sudden screams, aggressive behaviour. These behavioural disorders can mask a depressive disorder, the key to diagnosis, in this case, being the information received from relatives.

Pseudodementia (A complete guide)

Conclusions

In this article, we talked about pseudodementia. We clarified the differences between pseudodementia and dementia, the signs, symptoms and risk factors of pseudodementia, and the treatment options available. We also talked about the signs and the implications of depression in old age. 

Pseudodementia describes cognitive deficits in depression or other psychiatric illnesses in the elderly. It can occur in many psychiatric illnesses, but more frequently in mood disorders, and “mimics” a clinical picture of dementia. The cognitive problems experienced in these cases are due to mental disorders, not damage to the central nervous system.

Cognitive deficits in pseudodementia are grouped into 3 categories: memory, executive functions and language. In terms of age, depression can occur at any age, but pseudodementia is usually found in middle-aged or elderly people.

If you have any questions, comments or recommendations, let us know in the comments section! 

Further reading

Pseudodementia: A Theoretical and Empirical Discussion (Case Western Reserve Geriatric Education Center. Interdisciplinary monograph series), by V. Olga Beattie Emery 

The 10-Step Depression Relief Workbook: A Cognitive Behavioral Therapy Approach, by Simon Rego PsyD 

An Experimental Investigation of Simulation and Pseudo-Dementia (Acta Psychiatrica et neurologica Scandinavica. suppl. 132.), by Edward William Anderson

References

Beer MH, Berkow R, eds. The Merck Manual of Diagnosis and Therapy. 17th ed. Somerset, NJ: John Wiley and Sons; 2005.

Kang H, Zhao F, You L, et al. Pseudodementia: A neuropsychological review. Ann Indian Acad Neurol. 2014;17(2):147-154. 

Kang H, Zhao F, You L, Giorgetta C, D V, Sarkhel S, Prakash R. Pseudo-dementia: A neuropsychological review. Ann Indian Acad Neurol. 2014 Apr;17(2):147-54.

Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Practice. 5th ed. St Louis: Mosby; 2002.

Sweet RA, Hamilton RL, Butters MA, et al. Neuropathologic correlates of late-onset major depression. Neuropsychopharmacology. 2004

Wells CE. Pseudodementia. Am J Psychiatry. 1979;136:895-900.

Pseudodementia (A complete guide)

Nadejda Romanciuc

Nadejda Romanciuc holds a Bachelor’s degree in psychology and a diploma in Addiction studies. She is part of the Romanian Association of Integrative Psychotherapy as a psychotherapist under supervision. She's practicing online counselling for over two years and is a strong advocate for mental health.