What is pseudodementia?

Understanding pseudodementia

Pseudodementia is a condition that develops alongside psychiatric conditions like depression. It does not represent neurocognitive dementia, such as in cases of Alzheimer’s. Rather, it is secondary to other psychiatric conditions.

The reason the condition is called pseudodementia is that it involves symptoms that look similar to dementia, but it is a separate condition from organic dementia. Much like dementia, pseudodementia includes symptoms of cognitive decline, such as difficulty with memory or executive functioning.

What causes it?

Pseudodementia is often caused by depression, and in some cases, the condition is called depressive cognitive disorder. According to researchers, long-term inflammation from depression can lead to deficits in cognitive functioning ^[2].

Other factors that contribute to pseudodementia include the effects of depression on specific brain regions involved in learning and memory. Impairment in these brain regions can lead to cognitive deficits that appear similar to symptoms of dementia ^[2].

Finally, psychological and environmental factors, such as abuse, loss of a job, lack of social support, and other stressors can take a negative toll on physiological functioning and lead to cognitive decline. Some people may also have genetic risk factors for pseudodementia ^[2].

How is it diagnosed?

Pseudodementia is not an official diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Instead, it is an unofficial term used to refer to cognitive impairment that occurs with psychiatric disorders, typically depression. There are no official diagnostic criteria for the condition, but a doctor or clinician may use the term pseudodementia to refer to cognitive impairment that occurs with depression ^[2].

A physician or mental health professional diagnosing pseudodementia will take a full history, which involves asking questions about a patient’s medical history, mental health history, and history of symptoms. The clinician making a diagnosis will ask about the onset and duration of symptoms, and they may complete assessments of memory and learning, as well as laboratory testing and brain scans, to rule out neurodegenerative causes of cognitive decline.

To determine if a person has major depressive disorder, a clinician will utilize diagnostic criteria in the DSM-5. Major depression is diagnosed when a person has a depressed mood or a loss of interest in activities, accompanied by at least four other depression symptoms, such as low energy, sleep changes, feelings of worthlessness, and suicidal ideation ^[3].

A person may be said to have pseudodementia if they have depressive symptoms, accompanied by signs of cognitive impairment, which can include difficulty with concentration, memory, and information processing ^[1].

What are the symptoms of pseudodementia?

Since pseudodementia is most often associated with cognitive impairments that occur alongside depression, the signs of pseudodementia include depression symptoms accompanied by evidence of cognitive deficits.

Some common symptoms of depression that occur in pseudodementia include ^[3]:

• Sad or depressed mood
• Lack of interest in usual activities or hobbies
• Difficulty with concentration or decision-making
• Change in weight (either weight loss or weight gain) without attempting to change weight
• Change in sleep habits, which can involve sleeping either too much or too little
• Feeling an inappropriate amount of guilt, or struggling with feelings of worthlessness
• Changes in motor activity, which can manifest in the form of either restlessness or noticeably slowed movements
• Feeling extremely fatigued and/or having a hard time completing daily activities due to low energy and lack of productivity
• Thoughts of suicide or suicide attempts

In addition to the depression symptoms above, someone with pseudodementia will show signs of cognitive impairment, which can include ^[1]:

• Difficulty with speech
• Impairments in learning
• Memory loss
• Having a hard time paying attention or shifting attention between tasks
• Problems with planning and organizing
• Trouble regulating emotions

Pseudodementia vs Dementia

While pseudodementia that occurs with depression can look similar to dementia, the two are distinct conditions. Firstly, dementia is a neurocognitive condition associated with pathology and abnormalities within the brain. In organic dementia, these abnormalities are not reversible. On the other hand, cognitive decline in pseudodementia is often reversible with successful treatment. 

That being said, there is some evidence that pseudodementia can increase the risk that a person will develop irreversible dementia in the future. Early treatment and intervention can reverse cognitive decline in depression and lower the risk of future neurodegenerative diseases, including dementia ^[4]. 

Finally, cognitive impairment in dementia is often more severe than what is seen with pseudodementia. Patients who have cognitive impairments alongside depression may have only mild difficulties with memory and concentration, whereas these impairments are more severe in dementia and can interfere with daily functioning. In fact, a recent study found that patients with dementia performed worse on all cognitive tests when compared to patients with pseudodementia from depression ^[5].  

What treatment options are available?

Since pseudodementia involves cognitive decline that occurs secondary to symptoms of depression, treating the depression often results in an improvement in cognitive functioning. One study with 284 patients found that over the long-term, 53% of patients no longer showed symptoms of dementia or cognitive impairment ^[4].

Common treatment options that can reverse cognitive dysfunction in pseudodementia include ^[6]:

• Therapy: Specific therapeutic modalities, including cognitive remediation therapy and cognitive behavioral therapy (CBT) can improve cognitive functioning inpseudodementia patients. In fact, studies have shown that therapy can actually produce changes in brain functioning and connectivity in patients with depression, therapy reversing cognitive impairments. Therapies used in the treatment of pseudodementia can help patients to change distorted thinking patterns and learn new skills.
• Medication: Prescription drugs used in the treatment of depression have been found to improve cognitive functioning, which suggests these medications can be beneficial for treating pseudodementia. Two types of antidepressant medications called selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been found to be particularly effective for alleviating cognitive impairment in depression. Specific medications within these classes include sertraline and duloxetine, and studies suggest that both are effective for treating cognitive impairment. Another type of antidepressant drug, called vortioxetine, has been proven effective for treating cognitive dysfunction.
• Brain Stimulation: Various brain stimulation methods are used in the treatment of depression, and they may be beneficial for treating pseudodementia. Electroconvulsive therapy (ECT) is one method of brain stimulation, but its use is controversial, because it can cause short-term cognitive impairment after treatment. After the cognitive side effects of ECT pass, it is associated with small to medium improvements in memory, information processing, and executive functions. Transcranial magnetic stimulation (TMS) is a less invasive alternative to ECT, and this brain stimulation method has been found to be beneficial for reducing cognitive impairment in depression. 

Pseudodementia is a psychiatric condition that mirrors the symptoms of organic dementia, but it differs from the latter, because it is not a legitimate neurocognitive disorder. It is important to remember that pseudodementia is a descriptive term that refers to cognitive decline that occurs with depression or another psychiatric condition, but it is not an official diagnosis. Furthermore, it is worth noting that if left untreated, pseudodementia does increase the risk that a person will develop organic dementia. Treatment can reverse cognitive decline and reduce the risk of complications or worsening of pseudodementia.