Psychiatry · Year 3 · from Psychiatry
Case 1: Late-Life Depression with Pseudodementia
Patient Demographics
- Age: 76 years old
- Sex: Female
- Occupation: Retired nurse
- Living Situation: Lives alone, widowed 6 months ago
Chief Complaint
Per daughter: "Mom can't remember anything anymore. I'm worried she has Alzheimer's like grandma."
History of Present Illness
The patient is a 76-year-old woman brought by her daughter for evaluation of memory problems that began approximately 4-5 months ago, shortly after her husband of 52 years died from pancreatic cancer. The daughter reports her mother has difficulty remembering recent conversations, missed several appointments, forgot to pay bills (for the first time ever), and got confused while driving to the grocery store she's been going to for decades.
On interview, the patient appears withdrawn and apathetic. She frequently responds "I don't know" to questions before attempting to answer. When encouraged to try, she often answers correctly. She is slow to respond and appears to have difficulty concentrating.
The daughter reports additional concerns: Her mother has stopped attending her bridge club, lost 12 pounds, sleeps poorly, and has expressed statements like "I wish I could be with Harold" and "What's the point of going on?" She has stopped cooking and often doesn't eat unless her daughter brings food. The house, which was always immaculate, is now cluttered and dirty.
Past Psychiatric History
- One episode of depression 20 years ago after her mother died; treated with "a medication" for about a year, recovered fully
- No history of cognitive impairment prior to husband's death
- Was sharp, managed household finances, active socially
Medical History
- Hypertension (controlled)
- Osteoarthritis
- Hypothyroidism (on levothyroxine)
Mental Status Examination
Appearance: Thin elderly woman, clothes wrinkled and stained, hair disheveled, poor hygiene, appears older than stated age
Behavior: Psychomotor retardation, poor eye contact, sighs frequently
Speech: Slow rate, soft volume, long latencies before responding
Mood: "Empty... I just don't care about anything anymore"
Affect: Flat, constricted, tearful when discussing husband
Thought Process: Impoverished, slow but linear
Thought Content:
- Pervasive hopelessness
- Passive suicidal ideation ("I wish I could be with Harold, I wish I wouldn't wake up")
- No active suicidal ideation, plan, or intent
- No psychotic symptoms
Cognition:
- MoCA: 22/30
- Lost points on delayed recall (0/5 with no improvement with cues)
- Lost points on attention tasks
- Orientation intact
- Key observation: "I don't know" responses initially, then correct answers with encouragement
- APPEARS more impaired than she IS
Comparison: Pseudodementia vs. Dementia
| Feature | This Patient | Typical Alzheimer's |
|---|---|---|
| Onset | Relatively rapid (months) | Insidious (years) |
| Temporal relationship | After husband's death | No clear precipitant |
| Patient's awareness | "I can't remember anything" | Often unaware/minimizes |
| Effort on testing | Low ("I don't know") | Tries hard but fails |
| Response to encouragement | Improves with support | No change |
| Memory pattern | Variable | Consistent impairment |
| Mood | Clearly depressed | May be preserved early |
| Previous episodes | Yes (depression) | N/A |
Diagnosis
Major Depressive Disorder, Recurrent, Severe, with Cognitive Impairment ("Pseudodementia") (F33.2)
Evidence:
- Depressed mood
- Anhedonia (stopped bridge, cooking, activities)
- Weight loss (12 lbs)
- Sleep disturbance
- Psychomotor retardation
- Fatigue/low energy
- Worthlessness implied
- Passive suicidal ideation
- Cognitive difficulties (secondary to depression)
- Clear temporal relationship to husband's death
- Prior depressive episode
- Cognitive impairment pattern more consistent with depression than dementia
Key Teaching Point: "Pseudodementia" = cognitive impairment caused by depression that improves with depression treatment. Important to distinguish from true dementia, as treatment approaches differ dramatically.
Treatment Plan
1. Safety:
- Passive suicidal ideation without plan - moderate risk given isolation, recent loss, and hopelessness
- Increase social contact (daughter to check daily)
- Safety plan developed
- Remove firearms if any (there are none)
- Consider hospitalization if worsens
2. Pharmacotherapy:
- Sertraline 25 mg daily, titrate to 50 mg in 1 week
- SSRI preferred for geriatric depression
- Avoid TCAs (anticholinergic effects worsen cognition, cardiac risk)
- Lower starting dose in elderly
- Expected timeline: 4-8 weeks for full effect
- Monitor closely for response
3. Psychotherapy:
- Supportive therapy initially
- Grief-focused therapy for complicated bereavement
- Behavioral activation: structured activities, social contact
- Problem-solving therapy for practical issues
4. Social Support:
- Assess home safety (can she manage alone?)
- Consider home health aide
- Meals on Wheels or similar
- Re-engage with social activities (bridge club) as depression improves
- Grief support group
5. Follow-up:
- Weekly appointments initially
- MoCA repeated in 6-8 weeks to assess cognitive improvement with depression treatment
- If cognition does not improve with depression treatment, further dementia workup needed
Expected Outcome
With treatment of depression, cognitive function should significantly improve. If this is true pseudodementia, her MoCA should normalize or near-normalize. If cognitive impairment persists despite depression remission, underlying dementia should be considered.