Psuedodementia

[neoexile]

Okay. I need help.

I had a discussion with one of my interviewers about "Psuedodementia". I was wondering if this is actually a real diagnosis or is this depression unmasking real dementia?

I always thought it was depression that was so severe that it causes a clinical picture of dementia. However, it isn't progressive or stepwise, usually has a proximal stressor and no other medical causes can be ruled in. What do people think?

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[WisNeuro]

We don't use this term any longer. It is inaccurate, at best.

 

[neoexile]

We don't use this term any longer. It is inaccurate, at best.

Wait so if a patient presents with dementia, but there is a proximal stressor with negative medical testing and his ADLs/IADLs were intact, it's depression unmasking actual dementia?

What is the current understanding of psuedodementia then? Does this mean that treating the depression will not help with regards to reversing the dementia?

 

[thoffen]

Firstly, major neurocognitive disorder (dementia) is differentiated from mild (MCI) by impairment in independent function, not by the specific cognitive deficits or degree of impairment within them. If someone is still fully independent (even with modifications to their methods of performing their IADLs), they do not have dementia as a psychiatric diagnosis.

I think what you are better asking is about someone having an underlying dementing illness, e.g. Alzheimer's disease, and whether cognitive symptoms in the context of a major depressive episode represents a two-hit process or represents only depressive symptomatology independent of underlying dementing illness.

The answer is both. Absolutely people can have significant cognitive impairment from depression without underlying dementing illness, and absolutely underlying dementing illness may be a huge part of someone's significant decline in the context of depression.

I will add also that depressive symptomatology is often a result of a dementing illness (even in MCI stage), and of course psychological conflicts about aging and declining are hugely important in geriatric depression.

I don't think definitional precision is all that possible. What we need is capacity to look for, evaluate, treat, and render prognosis to the greatest of our ability to patients/families in this situation. In each case, we are offering our best without absolute certainty.

 

[neoexile]

Firstly, major neurocognitive disorder (dementia) is differentiated from mild (MCI) by impairment in independent function, not by the specific cognitive deficits or degree of impairment within them. If someone is still fully independent (even with modifications to their methods of performing their IADLs), they do not have dementia as a psychiatric diagnosis.

I think what you are better asking is about someone having an underlying dementing illness, e.g. Alzheimer's disease, and whether cognitive symptoms in the context of a major depressive episode represents a two-hit process or represents only depressive symptomatology independent of underlying dementing illness.

The answer is both. Absolutely people can have significant cognitive impairment from depression without underlying dementing illness, and absolutely underlying dementing illness may be a huge part of someone's significant decline in the context of depression.

I will add also that depressive symptomatology is often a result of a dementing illness (even in MCI stage), and of course psychological conflicts about aging and declining are hugely important in geriatric depression.

I don't think definitional precision is all that possible. What we need is capacity to look for, evaluate, treat, and render prognosis to the greatest of our ability to patients/families in this situation. In each case, we are offering our best without absolute certainty.

Damn. Well psychiatry is a nebulous field with no exact answers. =/

And this is the difference between answering questions for boards and actually practicing. There is a lot here I feel like you won't know unless you specialize in the field. I always thought that psuedodementia was a thing up until my interview. Now I have to revisit it completely and redefine my knowledge.

 

[WisNeuro]

Well, the issue at hand is subjective vs objective cognitive impairment. People with depression actually don't have objective cognitive impairment once you control for effort and/or malingering. The subjective problems are more due to motivation and activation of cognitive resources rather than an actual neurological problem in the areas of the brain necessary for things like memory.

 

[thoffen]

Well, the issue at hand is subjective vs objective cognitive impairment. People with depression actually don't have objective cognitive impairment once you control for effort and/or malingering. The subjective problems are more due to motivation and activation of cognitive resources rather than an actual neurological problem in the areas of the brain necessary for things like memory.

While that trend is clearly observable, I'm not aware of any way to validate such an impression using objective criteria. But I see you're a neuropsychologist, so I'm quite positive you know more about this than I do. Outside of malingering, are there any validated tests that have such an objective measure, or is it all based on clinical observation of effort/interpretation of pattern of deficits seen/clinical history?

 

[WisNeuro]

While that trend is clearly observable, I'm not aware of any way to validate such an impression using objective criteria. But I see you're a neuropsychologist, so I'm quite positive you know more about this than I do. Outside of malingering, are there any validated tests that have such an objective measure, or is it all based on clinical observation of effort/interpretation of pattern of deficits seen/clinical history?

Clinical observation, PVT/SVT performance, performance on objective memory testing is all we need, we see it all the time, fairly easy to pick up and distinguish if you have a moderate to heavy gero patient load.

 

[PsyDr]

While that trend is clearly observable, I'm not aware of any way to validate such an impression using objective criteria. But I see you're a neuropsychologist, so I'm quite positive you know more about this than I do. Outside of malingering, are there any validated tests that have such an objective measure, or is it all based on clinical observation of effort/interpretation of pattern of deficits seen/clinical history?

There are many well validated tests for effort. Malingering is only one explanation for low effort.

Cognitive tests measure ability, not performance. One cannot make an aphasic perform in the normal range in expressive language tests (generally). That ability and tissue is gone. One can get a similar score from a hostile or uncooperative patient. But the difference is that in the latter case you can get a normal score if the underlying problem is treated.

 

[smalltownpsych]

We don't use this term any longer. It is inaccurate, at best.

Didn’t know this as I still hear this term used out here in the sticks. I thought that it was theoretically possible, but my experience has also been that it has been relatively easy to differentiate. So I am glad to put it to rest.

The one case that was a little different was during a neuro practicum with a 40 year old patient with suspected prion disorder. We were retesting them after a year and results were the same which appeared to rule out prion disorder. I suspected depression and perhaps much more significant mental illness. Case was presented at the neurology grand rounds, but it was on a day I was stuck in class so couldn’t make it. I did hear that they threw out. A lot of wild speculations that didn’t fit the case. My recommendation was for psychotherapy and psychotropics because the patient did seem to improve a bit when interacting with me ( and I could be pretty therapeutic even then ). Besides if we couldn’t find anything else to fix, it was worth a shot to address the depression. I guess it’s just one of those cases I still think about from time to time and wonder whatever happened.

 

[splik]

We don't use this term any longer. It is inaccurate, at best.

Who is we? The term has largely disappeared from the literature (alas) but neuropsychiatrists and behavioral neurologists still use it in clinical practice, as do general psychiatrists. You are right, it is not a very specific term and conflates a number of distinct clinical presentations, but we use to describe those patient presenting with subjective cognitive impairment/memory complaints who are quite clearly depressed. We (that is neuropsychiatrists) don't refer for neuropsychological testing because the poor effort is often evident (and the hallmark of the condition) on basic clinical evaluation and it's a waste of everyone's time to do neuropsych testing. We just treat empirically and refer only if they fail to respond to treatment (at which point it usually becomes clear something else is going on). The diagnosis was popularized at a time when patients with cognitive disturbances were all labeled as demented and there was no attempt in clinical practice to distinguish between treatable depression, delirium, and dementia. That was an important step as many patients with treatable disturbances of cognition were left to languish. Of course this is an oversimplification too, and in reality, all 3 can and do co-exist.

The problems are:
1. patients with "depressive pseudodementia" are more likely to develop dementia
2. depression can be the harbinger of a dementing process
3. depression accelerates cognitive decline in patients with a neurodegenerative disease (i.e. AD)
4. depression with co-morbid cognitive impairment responds more poorly to treatment
5. true cognitive deficits in late-life depression are usually caused by dementing process
6. the diagnosis of pseudodementia may mask a rare disease (for example there are case reports of refractory depressive pseudodementia in those with the C9orf72 hexanucleotide repeat expansion or semantic dementia)

 

[WisNeuro]

We is the medical community at large, at least in the areas that I have worked and trained in. There are much better terms that do not convey inaccuracies, iatrogenic damage, or lead to mistreatment.

 

[clausewitz2]

We is the medical community at large, at least in the areas that I have worked and trained in. There are much better terms that do not convey inaccuracies, iatrogenic damage, or lead to mistreatment.

Please explain why "pseudodementia" causes iatrogenic damage and "poor effort/motivation" does not.

 

[WisNeuro]

Please explain why "pseudodementia" causes iatrogenic damage and "poor effort/motivation" does not.

Because the belief that one has a degenerative disease, with no cure or medication to ease it, tends to increase feelings depression and hopelessness. There is a bevy of literature on the iatrogenic effects of stereotype threat and misdiagnosis. This is in addition to the fact that most patients who have been told that they have "pseudodementia" that I have seen, do not know that it is different than actual dementia. Whether or not it's due to a poor explanation from their physician, or some other misunderstanding is really irrelevant considering the outcome.

Discussing how a patient's low motivation and initiation of cognitive effort, possibly secondary to their depression, can lead to positive discussions and hopefully motivation to begin certain interventions (e.g., behavioral activation strategies).

 

[neoexile]

Who is we? The term has largely disappeared from the literature (alas) but neuropsychiatrists and behavioral neurologists still use it in clinical practice, as do general psychiatrists. You are right, it is not a very specific term and conflates a number of distinct clinical presentations, but we use to describe those patient presenting with subjective cognitive impairment/memory complaints who are quite clearly depressed. We (that is neuropsychiatrists) don't refer for neuropsychological testing because the poor effort is often evident (and the hallmark of the condition) on basic clinical evaluation and it's a waste of everyone's time to do neuropsych testing. We just treat empirically and refer only if they fail to respond to treatment (at which point it usually becomes clear something else is going on). The diagnosis was popularized at a time when patients with cognitive disturbances were all labeled as demented and there was no attempt in clinical practice to distinguish between treatable depression, delirium, and dementia. That was an important step as many patients with treatable disturbances of cognition were left to languish. Of course this is an oversimplification too, and in reality, all 3 can and do co-exist.

The problems are:
1. patients with "depressive pseudodementia" are more likely to develop dementia
2. depression can be the harbinger of a dementing process
3. depression accelerates cognitive decline in patients with a neurodegenerative disease (i.e. AD)
4. depression with co-morbid cognitive impairment responds more poorly to treatment
5. true cognitive deficits in late-life depression are usually caused by dementing process
6. the diagnosis of pseudodementia may mask a rare disease (for example there are case reports of refractory depressive pseudodementia in those with the C9orf72 hexanucleotide repeat expansion or semantic dementia)

Might be a specific question but I need to ask. Do 80% of cases of psuedodementia actually progress to real dementia? What's your take on it?

 

[clausewitz2]

Because the belief that one has a degenerative disease, with no cure or medication to ease it, tends to increase feelings depression and hopelessness. There is a bevy of literature on the iatrogenic effects of stereotype threat and misdiagnosis. This is in addition to the fact that most patients who have been told that they have "pseudodementia" that I have seen, do not know that it is different than actual dementia. Whether or not it's due to a poor explanation from their physician, or some other misunderstanding is really irrelevant considering the outcome.

Discussing how a patient's low motivation and initiation of cognitive effort, possibly secondary to their depression, can lead to positive discussions and hopefully motivation to begin certain interventions (e.g., behavioral activation strategies).

I find the idea that someone would inform a patient that "your diagnosis is pseudodementia" very weird but I believe you that this has happened in your part of the world. I have never seen it as anything other than a term professionals use to communicate with each other to mean basically the picture of poor motivation/effort initiation that you are describing that causes someone to look like they are cognitively impaired on rudimentary screening tests. You have to remember that most of us practice in contexts in which doing a MoCA is basically seen as highly rigorous psychological testing.

I am suspicious of stereotype threat literature a priori because there have been serious replication problems with stereotype threat paradigms in many contexts but I will take your word for it.

Given that physicians use pseudodementia to mean "not actually dementia", I am not sure that it causes misdiagnosis problems per se. It does sound like in the contexts in which you've been in it leads to serious communication problems with patients and I can see why it should never be used when actually speaking to someone about their diagnosis.

Perhaps you practice in a place or setting where you get told to f*ck yourself less often, but I am not sure that most of the people I see would respond very well to being told "the problem is you're just not trying hard" which is exaaaactly what some people are going to mentally translate that into, versus "your depression is making it hard for you to do this test", which is absolutely what I understand by pseudodementia.

 

[WisNeuro]

Given that physicians use pseudodementia to mean "not actually dementia", I am not sure that it causes misdiagnosis problems per se. It does sound like in the contexts in which you've been in it leads to serious communication problems with patients and I can see why it should never be used when actually speaking to someone about their diagnosis.

This is a world where patients have immediate access to their charts and many of the notes within it. It is not infrequent that I have a patient asking me about their "diagnosis." Much of my job is psychoeducation and clarifying mistakes from other providers.

Perhaps you practice in a place or setting where you get told to f*ck yourself less often, but I am not sure that most of the people I see would respond very well to being told "the problem is you're just not trying hard" which is exaaaactly what some people are going to mentally translate that into, versus "your depression is making it hard for you to do this test", which is absolutely what I understand by pseudodementia.

I think you are making many incorrect assumptions about effort/validity in general (e.g., it is not a categorical variable) and also how this feedback is administered to patients.

 

[clausewitz2]

This is a world where patients have immediate access to their charts and many of the notes within it. It is not infrequent that I have a patient asking me about their "diagnosis." Much of my job is psychoeducation and clarifying mistakes from other providers.

That makes sense. I am in a system where patients struggle to get access to their charts through a byzantine and incompetent bureaucracy so I admit it is less of an issue for me to date.

I think you are making many incorrect assumptions about effort/validity in general (e.g., it is not a categorical variable) and also how this feedback is administered to patients.

No, I am very much aware that it is not a categorical variable. While not a psychologist by training I did my graduate work in adjacent fields so am not 100% unfamiliar with this literature. I am responding to the suggestion that what we should document is poor effort rather than pseudodementia and how I imagine some of my patients responding to this (when, for example, they read it in notes they have obtained) or when someone who is not very good at providing this feedback shares this particular "diagnosis" with them. I am sure it is a group that is not entirely isomorphic to the group that will be intensely demoralized by suggestions of a dementing illness.

I guess what I'm trying to say is it seems like there is very little ground here for staking out absolute positions like "this term is inappropriate and terrible in all circumstances and you are sort of a bad/ignorant person if you continue to use it", which is sort of the vibe of your posts. Your concerns about it make sense and I am very unlikely to use it myself (because I avoid jargon whenever possible) but it does convey a succinct message in conversations between providers. I see your points about not putting this down as a diagnosis, which, as it describes a phenomenon rather than a diagnostic entity, does seem silly and pointless.

 

[WisNeuro]

No, I am very much aware that it is not a categorical variable. While not a psychologist by training I did my graduate work in adjacent fields so am not 100% unfamiliar with this literature. I am responding to the suggestion that what we should document is poor effort rather than pseudodementia and how I imagine some of my patients responding to this (when, for example, they read it in notes they have obtained) or when someone who is not very good at providing this feedback shares this particular "diagnosis" with them. I am sure it is a group that is not entirely isomorphic to the group that will be intensely demoralized by suggestions of a dementing illness.

Then you should be aware that there are a myriad of different ways to document and discuss the issue. Depending on the severity/pattern of performance invalidity, in conjunction with the patient history and presentation, most of us who do this well have a dozen plus ways that we do this. We also make sure that we and the referring provider are on the same page when we deal with such issues, as that can cause some problems if it s not so.

I guess what I'm trying to say is it seems like there is very little ground here for staking out absolute positions like "this term is inappropriate and terrible in all circumstances and you are sort of a bad/ignorant person if you continue to use it", which is sort of the vibe of your posts. Your concerns about it make sense and I am very unlikely to use it myself (because I avoid jargon whenever possible) but it does convey a succinct message in conversations between providers. I see your points about not putting this down as a diagnosis, which, as it describes a phenomenon rather than a diagnostic entity, does seem silly and pointless.

The position is that it's an outdated and generally inaccurate term that leads to a lot of miscommunication and bad information transfer. People aren't "bad/ignorant" for using it, they're simply outdated in their beliefs, or practice in an area where that is still commonplace. Things change at different speeds in different areas. About the succinct message that it conveys, I tend to disagree, because I often have providers asking for clarification, or asking questions about pseudodementia that makes it very clear that they hold some very false beliefs about it. I hardly see something as silly and pointless when it leads to so many problems, be it within patients, or providers.

 

[clausewitz2]

Then you should be aware that there are a myriad of different ways to document and discuss the issue. Depending on the severity/pattern of performance invalidity, in conjunction with the patient history and presentation, most of us who do this well have a dozen plus ways that we do this. We also make sure that we and the referring provider are on the same page when we deal with such issues, as that can cause some problems if it s not so.



The position is that it's an outdated and generally inaccurate term that leads to a lot of miscommunication and bad information transfer. People aren't "bad/ignorant" for using it, they're simply outdated in their beliefs, or practice in an area where that is still commonplace. Things change at different speeds in different areas. About the succinct message that it conveys, I tend to disagree, because I often have providers asking for clarification, or asking questions about pseudodementia that makes it very clear that they hold some very false beliefs about it. I hardly see something as silly and pointless when it leads to so many problems, be it within patients, or providers.

Yeah I guess at the end of the day we have simply worked in very different settings and have had very different experiences. I am sorry you have worked with so many crappy physicians, it must be very frustrating.

 

[WisNeuro]

Yeah I guess at the end of the day we have simply worked in very different settings and have had very different experiences. I am sorry you have worked with so many crappy physicians, it must be very frustrating.

Meh, work long enough and in enough settings and you'll work with plenty of crappy providers across the spectrum of specialties. Most are great, but the crappy ones make everyone's job that much harder and make some issues much more salient.