Depression versus Dementia

Imagining depression is having a brutal and vicious battle with dementia is very thought-provoking is it not???

However, this war is incredibly real and requires our most serious consideration.

Living with depression may increase levels of impaired perception, increase confusion, create rapid functional and cognitive decline, and intensify changed behaviour.

If we examine this realistically, we may establish that depression may be viewed as an insidious condition which may override and exacerbate any other disease/illness that it superimposes itself upon, generating inaccurate primary diagnosis, poor assessment of needs, and gross decline in quality of life.

Depression only requires a person to be vulnerable and exposed, to commence its savage cycle.
Those who live with dementia are therefore immediately more susceptible to depression taking over in this manner, thus destroying their existence, and ability to positively age.

I wonder why, when people are experiencing such a plethora of major changes in their life, such as loss of abilities and independence, grief, trauma, living with numerous co-morbidities/chronic illness, (including a diagnosis of dementia), and are being forced to face their own mortality, is depression not always identified, or is incorrectly considered a symptom associated with the progressive nature of dementia??

I therefore challenge and question why society is neglecting to recognize and address an issue that is resolvable and treatable.
Should they not instead choose to proactively empower and enable people living with dementia to maximize their quality of life WITHOUT the interference of depression???

Evidence suggests approximately 52% of people residing within residential aged care facilities, are living with an undiagnosed and untreated depression. (Australian Institute of Health and Welfare, 2013).
This figure is a major concern.

It has additionally been estimated that depression, or depressive symptoms, may occur in 20-30% of people who live with dementia, and that people who reside in residential aged care are at higher risk.
Dementia Australia (2022), and Zubenko GS, Zubenko WN, and McPherson S, (2002), suggest that 30%–50% of dementia cases are accompanied by depression.

Hence it is reinforced that in the case of people living with dementia, depression continues to be normalised, and mistakenly viewed as a common symptom of dementia.
This assumption leads to subjective and inefficient assessment processes, in which people living with dementia may suffer potentially for decades with both dementia and depression, all because of the inability to view depression and dementia as two separate medical conditions.

Therefore, it is necessary that we effectively create a niche care model for those living with dementia, by acknowledging that depression is evidently more than occasionally undiscovered, undiagnosed, or ignored, so they may respectfully live their best life unhampered by the addition and/or onset of clinical depression.

It is consequently imperative we scrutinise the methods currently utilised to assess the individualised needs of a person, whilst upholding a person-centred approach to care, whilst always considering a person’s true presentation may be falsely camouflaged by the sinister symptoms of depression.

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This study examines the prevalence of people living with dementia and depression in a residential aged care facility and provides solutions and recommendations that may successfully avoid the continuation of this particular debilitating scenario.

Important Factors:

Firstly, it is vital we acknowledge that along with the emotional trauma of being recently diagnosed with dementia, (and still retaining some insight), many older people are also dealing with ageing transitions, isolation, loss in the context of independence, grief, decline in physical health, widowhood, effects of medication interactions, polypharmacy, and often, chronic pain. These physical and biopsychosocial life shifts may be compounded by them having to move into a new and strange environment and live amongst a group of unfamiliar people.

Some may already have a significant previous history of depression or anxiety disorders, or further medical conditions that are ineffectively managed.

Somehow, I think that most of these factors would be depressing enough and not be conducive to wellbeing.

However, imagine the worst scenario, in which all the above were apparent, but you actually did NOT have dementia at all, and what seemingly presents as cognitive changes associated with dementia, is in fact chronic depression.

It defies the imagination to think how dreadful an error of this magnitude can cause – to sentence someone to a diagnosis of dementia for the rest of their time on this earth because health care workers have not identified a mental health condition that is not particularly difficult to identify.

Due to the similarities and parallels within the criteria recognized by the DSMV, and other validated, standardised criteria associated with depression and dementia, it has been recognised that the symptomology of both are very much the same and may mimic each other.

It would be very easy to draw the wrong conclusion if assessment was not accurate nor in depth in nature. Therefore, it is not acceptable to base a diagnosis of dementia on any of the following:

• Short term memory loss/forgetfulness
• Lethargy/loss of energy
• Loss of interest
• Changes in sleep patterns – (insomnia/hypersomnia)
• Sadness/worthlessness/tearfulness
• Increased emotion – crying/anger/hostility/agitation
• Decreased concentration
• Increase/decrease weight
• Psychomotor slowing
• Confusion Not only does this seem to be an uninformed, rigid and biased approach, but seems to flippantly negate the importance of an individual’s right in having an ‘accurate’ diagnosis.
  It should be recommended that there is nil to minimal room for error when diagnostic processes are implemented. It is imperative we always analyse precise information, so that our responses to this data ensures a person’s lifestyle and care is maximized in conjunction with the recognition of their own personal, specific, and individualized needs. Understanding and having the ability to differentiate between depression and dementia, is one of the crucial elements of avoiding misdiagnosis and promoting better practice in caring for older people.

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It is important to remember the following:

1. dementia like symptoms caused by a depression IS treatable.
2. depression should without fail, always be treated.

Dementia, delirium, and depression are considered the 3 most prevalent disabilities/mental disorders in the elderly age group.
They are commonly referred to as The 3 D’s. (Johnson, Sims and Gottlieb, 1994).

Data Collection Aims:

• ✓  Screening of a pilot group of 38 residents within a residential dementia enabling environment over a 12- month period, (2003-2004).
• ✓  Accurate identification of the prevalence of depression within this cohort of people.
• ✓  After identifying the incidence of depression superimposed on dementia, treatment to be commenced immediately.
• ✓  Accurate assessment of resident needs, whilst implementing established, and precise, individual care plans focusing on prevention and treatment of depression within an holistic approach to care.
• ✓  Promotion of better practice approaches to maximize quality of life, encouraging wellbeing instead of ill being.
• ✓  Reduction of stress related responses to unmet need.
• ✓  Reduction/prevention/cessation of the use of chemical restraint/overuse of psychotropics.
• ✓  Decreasing the margin of misdiagnosis of dementia. Interventions: Initial Interview: On meeting a potential client for the first time, it is necessary to delve into the pre-morbid lifestyle of that person, so that we develop a knowledge basis of their past, life transitions, health history, and “who they are as a person”, so that we can value their uniqueness, but also detect any anomalies.
  This should be a routine compulsory investigation made during all initial assessments. If the new client is not able to assist you in answering questions in relation to themselves, ensure you have a family member/s available, and medical history file, to provide perspective and/or answers to the following considerations. Important areas of consideration:

• past history of depression and anxiety/PTSD/other mental health disorders/delirium
• comprehensive health and medical history – current and past
• medication management
• head-to-toe assessment
• pain – neuropathic/musculoskeletal/other
• various investigation results – FBE/urine/Blood sugar/Cardiac/Respiratory/ECG/MMSE/depression scales/delirium screening/other
• functional ability – capabilities
• sensory loss
• cognitive changes – memory/insight/judgement/comprehension/reasoning
• cognitive changes – executive function/sequencing/reasoning/abstract thought/problem solving
• communication ability – comprehension/expression
• current or past relationships
• loss – spouse, children, family, and friends
• life history, career, hobbies, interests

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• routine, choices, and preferences
• evidence of acute changes in presentation Once this initial information has been collected, the data may be examined and utilised effectively to assist in evaluating whether depression is apparent or indicated at admission, and ongoing. Gathering information in relation to a persons’ life transitions, choices and medical history additionally permits you to alleviate distress for the person by respecting them as an individual when easing them into the essentially difficult and confronting move into residential aged care environments. Assessment Tools: These tools are commonly used for assessment purposes, to assist in identifying whether a person may present with a depressive illness.
  These tools are not considered an exhaustive list and it is important to note that further standardised tools may be interchanged to capture the same evidence. It is suggested that these assessment tools are conducted at initial assessment, annual assessment, discharge post 30 days in hospital, when there has been an acute change in a person’s mental/physical status, and regularly for any person who has an existing/ongoing diagnosis of depression.

1. Geriatric Depression Scale, (Yesavage et al, 1983)

This 30-question depression scale consists of 30 yes/no answers and is based on a scoring system.
A score of over 8-9 may indicate depression and would require further investigation.
It is recommended that only the 30-question scale is used, as opposed to the adjusted 15-question scale, given this could possibly provide inaccurate screening and results.
This tool is not designed for a person with a mini mental score of 22/30 or under, because the questions require memory to be intact, considerable insight, judgement, ability to problem solve, reason, calculate, and process information.
If a person is living with dementia, it is suggested that another tool is preferable.

NB: This tool is not considered a diagnostic tool, but a tool that indicates that depression may be apparent.

2. The Cornell Depression Scale, (Alexopoulos et al. 1988)

This scale is a 19-item scale, each rated over a 3-point continuum, and is designed to be utilised as an observational tool in which data is collected over a period of a week for signs and symptoms that may be interpreted as depressive symptoms.
Scores above 10 indicate a probable major depression.

Scores above 18 indicate a definite major depression.
Scores below 6 as a rule are associated with absence of significant depressive symptoms.
Interviews with the person, family members and caregivers may be included to support the observations if relevant. This tool is suggested as more appropriate to use for a person who has cognitive changes and is considered a more precise reflection of the potential presentation of depression in a person living with dementia, as it does not rely on responses that may not be clearly verbalised.

NB: This tool is not considered a diagnostic tool, but a tool that indicates that depression may be apparent.

3. The Mini Mental State Examination, (Folstein et al, 1975)

This tool consists of 30 specifically designed questions that evaluate cognitive ability and changes.
The Mini Mental is a thorough cognitive assessment that incorporates evaluation of short- and long-term memory, calculation, sequencing, judgement, insight, calculation, abstract thought, attention span, language/communication skills, and comprehension related to an individual’s cognitive function.

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This examination will not provide an accurate reflection of the persons true presentation and cognitive ability pre- treatment of depression, but it may demonstrate and measure the variance in cognition of a person living with dementia pre- and post-depression if conducted before and after treatment.

There is evidence to support that there are at times a significant improvement in mini mental scores, after depression is treated.

4. Behaviour Charting

Behaviour charting is helpful in the context that it may support and assist in completion of the Cornell Depression Scale by providing further observational data regarding behavioural responses that may be connected to the onset of depression.
It is advised that charting covers 24 hours and captures at least a 7-14-day period.

Care staff must be trained in understanding changed behaviour, and when completing charts, view, and document behaviour objectively without bias or prejudice.

To capture the relevance of linking changed or altered behaviour to depression, behaviour charting must be concise, clear, categorise the frequency and times behaviour occurs, show an understanding of the triggers to behaviour, the interventions implemented and the effectiveness of those interventions.

Collection of evidence of this nature can be of significant value to identifying the onset or prevalence of depression.

5. Further Investigations – Rule out Acute Delirium

When identifying the possibility of depression, assessment may include and require further investigations to ensure the persons presentation is not due to Acute Delirium, given this is the 3rd component of The 3 D’s, where the symptomology of Acute Delirium closely resembles that of depression, and/or dementia.

It is critical to recognise that these conditions may overlap concurrently, and a person may be diagnosed with depression, dementia, AND delirium.
This reinforces the need for accurate assessment to avoid a complex, intensely harrowing, and traumatic situation, where rapid deterioration may not be able to be successfully reversed.

The process of eliminating the possibility of Acute Delirium is therefore essential, to ensure assessment identifies the correct treatment is initiated for the correct condition.

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To conclude, a commitment to completing these assessments from the day of admission into RACF’s, throughout the initial month and a half, and/or at times where significant and rapid clinical deterioration is evident, should potentially allow a collation of data that may scrutinise whether a person has an undiagnosed depression, or positively prevent the onset of depression, whilst upholding a more informed decision-making approach to quality and dignified care.

If depression is indicated, then the results may be closely investigated by a clinician, the severity can immediately be estimated within mild, moderate, or severe parameters, and treatment can be initiated.

NB: Establishing a misdiagnosis of dementia is not possible at this stage.
If depression is successfully treated, further examination of cognitive function will ascertain whether a person’s cognitive changes were associated to depression and dementia, or chronic depression with no evidence of dementia.

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Treatment:

Treatment can be commenced immediately after depression has been identified.
A team-based approach is required, with input from GP’s, Registered Nurses, Specialists, Allied Health Professionals, caregivers, and family members.

It is suggested that all the following areas are considered in the treatment plan of a person living with dementia who has an underlying depression.

1. Anti-Depressants:

Initiating the use of anti-depressants immediately for someone living with dementia, may often improve or resolve depression quickly and effectively, with the hopeful conclusion being that the depression is cured entirely.

It is stressed however, that anti-depressants alone, will not cure depression.

It is usually advised, that, due to the occurrence of lesser side effects to the person taking the medication, SSRI, (selective serotonin uptake inhibitors), anti-depressants are promoted instead of the older tricyclics, which have a myriad of complications that are sometimes more debilitating than the condition they are used for.

If the medication prescribed is not effective after a period of about 4-6 weeks, it should be reviewed, changed, or ceased, so that further avenues may be explored.
Ongoing observation and monitoring at this time is necessary to evaluate results.

2. Medication Management:

In relation to the prescribed medications of any older person, it is necessary for a GP to review the dosage/effects of all medications ordered at least 3-6 monthly, and ongoing, to avoid adverse reactions and effects.

Older people are known to have slower metabolisms and excretion times as opposed to younger people, so blood toxicity levels may vary.

Therefore, levels of medication may accumulate in a person’s blood stream and precipitate adverse reactions and side effects, or overdose, in the worst-case scenario.
Furthermore, acute delirium may be triggered by harmful combinations of some medications and/or polypharmacy.

It is also recommended that regular pharmacy reviews and routine examination of polypharmacy is undertaken by a consultant pharmacist, to identify interactions between specific medications and make suggestions that are more viable for the individuals health and well-being.

If a resident is ingesting a combination of medications that may be the source of initiating depressive like symptoms, an alternative may need to be prescribed.

Reduction of the use of psychotropics, anti-anxiety, anti-psychotic and sedating medication is indicated, unless strictly necessary, and should be avoided, given the use of these medications can exacerbate the symptoms of dementia, and trigger depression and acute delirium.
The overuse/misuse of these medications is considered Elder Abuse.

Chemical restraint is never appropriate when administered and prescribed because a person is “different”, for castigation purposes, to make a caregiver’s life easier, or because of the person trying to communicate unmet need through changed behavioural responses.
This is considered a heinous practice and must be reported.

It is possible to establish what triggers and stressors are the source of communicative responses that may be viewed as behavioural, in a person who is living with depression and dementia, hence the use of non-pharmacological strategies is always advised.

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In the case of catastrophic instances only, PRN orders may be available, but used only as a last resort, when all other interventions have been exhausted and only if the person is considered an extreme risk to themselves or others.

3. Pain management:

It is necessary to undertake strict Pain Assessment, to evaluate whether a person is suffering from chronic, ongoing, relentless pain, or acute pain.
This should be established on admission, and an immediate and effective pain management regime initiated, and monitored ongoing, to avoid pain impacting negatively on quality of life.

This includes:

• Pain relief as per GP orders – documented reason why given, time, effect.
• If not effective, or numerous break-through pain relief is required, it is essential that the GP is contacted to review the pain management regime.
• Rest is recommended when affected by pain.
• Warmth – as in clothing, environment.
• Massage to affected areas.
• Heat packs to affected areas.
• Organising of ADLs around pain free times and post administration of pain relief.
• Increase assistance if pain is restricting ability to maintain independence.
• Encourage physical activity – tai chi, yoga, walking, physio.
• This not only improves strength, flexibility, and range, but can aid in reducing pain, and may expand upon self-worth, mobility, and balance.
• Elevation of limbs if pain is caused by poor venous blood flow to extremities.
• TENS machines.

4. Developing relationships/communication:

If a person is depressed it is extremely important to develop trusting relationships with the individual, to help them retain their self-worth, contribute meaning to their lives, and revitalise their ability to thrive.

Relationships with others are the central point in the life cycle of us all.

Social interaction, sitting, chatting, reminiscing, and laughing with another person, helps build trust and rapport, and allows development and continuation of those relationships that define who we are as a person.
If we take away all sense of belonging and independence from someone’s life, we are in fact removing the essence of what makes us human.

Suppose your life suddenly had eliminated from it, all meaningful communication.

“Envision how it would feel if you found yourself in a place where care was being delivered by a myriad of strange faces, who don’t understand you or how to communicate and build connections with you.
Their attitudes and actions effectively dehumanise you, make you feel worthless and inadequate, seem to remove your rights and dignity, and make you feel like all they see in front of them is a dementia diagnosis, as if it defines who you are”.

In these cases, it seems quite likely that depression will occur.

Wouldn’t you just love it if someone attempted to see your present from your perspective, or even just bothered to ask what YOU want?
How wonderful it must feel for them to realize and acknowledge that you are still the same person you have always been, only with some quirky cognitive changes and limitations.

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Now, imagine how isolating, problematic, and exasperating it must feel to be losing some abilities, or feel incapable of communicating verbally at times, when throughout a lifetime of experiences, you, and everyone else, has used this basic skill to interact with each other.
Envisage also, when those you are attempting to interact with, cannot understand you, because of their reliance on the verbal aspect of communication.

Communication is the glue that holds much of human life together, and a central stimulus within the individual life cycle of us all.
Through the ongoing development of, and the means we utilise to communicate, most human cultures have the ability to interchange information, concepts, mood and sensations.

Developing the ability to communicate effectively with other persons is one of the most crucial aspects within our evolution, as we often define ourselves based on how we develop our relationships with others throughout this time.

Without meaningful engagement and interaction, feelings of alienation and loss of comardarie may occur, and the person living with dementia may become isolated within their reality, hence live with a sense of lost identity.

Knowing how to communicate with a person who lives with dementia can mean the difference between them feeling lonely and remote, or recognized and valued.

Helpful interventions may include:

• ✓  Always greet a person by their preferred name and introduce yourself before you sit down with them.
• ✓  SMILE!!!!
• ✓  Avoid competing noises or activities as this can overstimulate and create confusion and stress.
• ✓  Move slowly – do not rush up to a person – people who rush make others feel anxious.
• ✓  Eye contact is very important to ensure someone recognizes that you are speaking to them.
  Facing someone, good lighting, reducing glare in the room, and ensuring glasses and hearing aids are in place if required is also crucial.
  Non-threatening eye contact includes engaging with a person on their level.
  This requires squatting down or lowering yourself and gently looking into a person’s eyes,
  Glaring down and looming over a person is intimidating and threatening.
• ✓  Never rush conversation – encourage responses with the person only if it seems they are comfortable in your presence.
• ✓  Simplify conversation, and do not over stimulate with too much information, as this can be confusing and overwhelming.
• ✓  Speak slowly, calmly, and gently always – never raise your voice because this can be perceived as anger or aggression.
• ✓  Allow time for the person to comprehend and process what has been said and to respond.
• ✓  Enter the individual reality of the person living with dementia – validate their journey.
• ✓  Don’t put unfair expectations on the person/be realistic as to the specific abilities of each person – keep in touch with their strengths and be understanding and compassionate as to their capabilities.
• ✓  Words are not the only form of communication so do not push for a verbal response – you may need to rely more heavily on non-verbal cues, tone, touch, body language, and attitude – because sometimes people with depression and/or dementia may respond more authentically with body language.
• ✓  Try to tune into the feelings rather than the content of information.
• ✓  Do not talk down to the person or treat as a child – never patronise.
• ✓  Show acceptance, be respectful and treat always with dignity – convey trust.
• ✓  Do not show annoyance in relation to repetition – treat the conversation as if it is the first time you have heard that information every single time and understand the impact of short-term memory loss.
• ✓  Do not put words into people’s mouths – this is disrespectful and rude.
• ✓  If you are unsure if the person has understood what has been said, you can repeat or rephrase what you have said.

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✓ Listen to answers and validate concerns.
✓ Talk about things that interest the person.
✓ Do not argue!!!!
✓ Avoid direct questions that require complex responses – instead use positive statements. ✓ Be VERY aware of your own body language – what we put out we receive in response.
✓ Humour can bring you closer together and is a great pressure valve.

Nonverbal communication is particularly important for a person living with dementia whose language skills are changing.

It is not unusual for us to become overly focused on the dialectical component of communication and assume that just because a person does not verbalise information in the manner we expect or prefer, they cannot communicate.

By observing a persons’ nonverbal responses, we may receive excellent messages in relation to how that person is feeling and responding to us.
In fact, it may be helpful for us to view this method of communicating as more authentic, honest, and real, than plain old lip service!

If we truly “listen” to what a person may be trying to express through their body language it may enable us to recognise that individual’s personal truth.

In relation to ourselves, we ought to be very attuned to our own body language.
If we are feeling rushed, frustrated, or anxious, ourselves, then we may inadvertently project our own negative energy onto another person.
This is not considered conducive communication and is an unproductive way to approach anyone.

People living with dementia, may mirror the confusing and harmful energy we at times, so thoughtlessly throw towards them, and when they respond by displaying ‘normal’ reactions to our approach, we unfairly label them as exhibiting “behaviour”.
The reality is. it is our behaviour that defines the behaviour in others!!!!

It is necessary that we acknowledge that we all display changed behaviour when our needs are not met, or when we are not happy about something, every single day, and throughout our entire life.

Of course, the same applies with the use of positive body language, and thus a momentum of joy may also be passed on to another, fostering feelings more attuned to happiness, warmth, and enthusiasm.

Hence it is evident that it is we who continue to have unfair expectations on people living with dementia, because WE are so dependent on the spoken word, and are so intent on misinterpreting their body language.

Consequently, it is our responsibility to become more flexible in how we communicate with them.
Instead of continuing attempts to relate to a person in the exact way we communicated with them prior to their cognitive changes, we should also attempt to develop a fresh and more successful method of communicating, whilst adapting, and respecting their capabilities.

Care staff should unfailingly approach clients with patience, kindness, and a soothing energy, and encourage the use of positive statements when speaking to a person who is depressed and lives with dementia.
E.g., Do not say, “You aren’t doing that the right way!”, which is negative, but instead, “You are doing a great job. Let me give you a hand.”

Continuity of staff is a significant factor when dealing with people who have memory loss and cognitive changes.
The person may not necessarily recognize you or know you by name, but with effective communication, you may discover how to build trust and rapport.
This is crucial in relationship building.

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Validation of a person’s reality is an area of great significance because it is only through recognition or affirmation that a person, and their feelings (or opinions), are valid and worthwhile, that you may, through empathy, build a sense of trust and security.
By acknowledge a person’s reality or thoughts may differ from yours, but is very real to them, may alleviate feelings of anxiety, nurture them, and provide much needed emotional support.

Hugging, holding hands, a kiss on the cheek, affection and physical contact is a wonderful way to communicate and pass positive and loving feelings on to someone else.
Of course, it is critical we never force affection on to a person who dislikes it, but firstly investigate whether they like to be touched, and whether they respond to touch favourably.

A greater sense of self-awareness on our part is worth reflecting upon before we approach a person who is down in the dumps.
Do avoid being overly cheerful if a person is severely depressed, as this can be extremely off- putting.
It is recommended that we do not inundate a depressed person with too much interaction, but instead, slowly, over time, introduce it, and observe the persons reactions to this.

We do not need to ‘talk’ all the time.

Just sitting with someone and providing non-invasive and peaceful companionship is an excellent way to open the lines up for further communication.
It is alright to sit in silence with someone who is severely withdrawn and show them that you accept their feelings without judgment.

By purely demonstrating that you are interested in the person is a very good starting point.

Lastly, try and touch the life of each person in a way that makes a positive impact.
If someone knows they have a friend or a confidant, this may lift their spirits considerably.

5. Converting ill-being into well-being:

Obviously physical and functional needs are considered vastly important in retaining a person’s ability, health and promoting a sense of wellbeing.

This includes ability to mobilise safely, sufficient intake, hygiene, grooming, going to the toilet, and all the fundamental activities of daily living.
These physical components are usually area’s that are tackled reasonably well when we examine the necessities related to general care, but there is much more involved in maintaining a person’s emotional wellbeing.

If a person is depressed and/or lives with dementia, they still ‘feel’ as intensely as they always have.
Cognitive changes do not change a person’s ability to feel emotion.
Feelings are organic and a person living with dementia may experience all those awfully, painful, and negative feelings such as frustration, anxiety, agitation, despair, embarrassment, fear, sadness, anger, low self-esteem, and loneliness. As with us all, these feelings will be closely associated with the manner in which we are treated by others.

People living with dementia, however, can easily be stimulated positively, and when their individual needs are met, may experience, every moment of every day, pleasure, delight, joy, wonder, contentment, peace, and happiness.

The basic foundations of wellbeing are simple – we all need purpose, meaning, to feel loved, valuable, and worthwhile.

If those feelings and emotions are destroyed, then the person may run the risk of having their self-worth crucified, resulting in them suffering internally, socially isolating themselves, becoming seriously withdrawn, and potentially sinking into depression.

Our aim here is to lift those overwhelming and debilitating feelings of ill-being and reverse them, enabling a person to recapture their life, and live with a sense of well-being.

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The essence of caregiving should be to innately desire and guarantee that every person we enter a care partnership with, benefits from the elements associated with biopsychosocial needs, purely because we ALL desperately crave for our existence to hold true meaning.

It is evident that we all need a sense of purpose to thrive, and for people living with dementia, it is truly our responsibility to contribute to enriching every moment thus assist them in retaining a healthy self-esteem.

To do this there are many areas of a persons’ life that need to be considered. I. Reducing the demands on a person:

It is not acceptable under any circumstance for us to expect a person who is unable to function as they did prior to their cognitive changes, to maintain the same skills they had when cognitively aware.
Nor should we compare people based on our own subjective cognitive abilities, because this is appallingly cruel and condemnatory.

Creating unfamiliar scenarios, and a whole new spectrum of change, where it is expected, a person will adapt to, or learn, may effectively set a person living with dementia up to fail, and may become incredibly confusing and traumatic. This is not productive, may be detrimental and harmful regarding how a person views themselves and thus affect their sense of self and the place they hold within the world.

Therefore, it is arbitrary and irrational for us to place unfair expectations onto any individual who has cognitive changes. Under no circumstance should we ever make demands that cannot be met, nor rush and push a person into achieving that which they can no longer maintain.
This may trigger embarrassment, confusion, anxiety, agitation, and resistiveness, that are a direct and “reasonable response” to feeling intimidated and overwhelmed.

It is vital that we avoid feelings of inadequacy in someone who has depression and lives with dementia, thus, it is essential we reduce unnecessary burden.

As caregivers, our goals should only be driven by providing the necessary amount of assistance required and involve an approach that caters to the needs of each person specifically.
This implies taking heed of a person’s retained strengths, instead of continually concentrating on the disability associated with dementia and/or depression.

Routine and regular activity allows people to feel comfortable within their own skin and often gives a person a sense of control over their own lives.
It is therefore always recommended that caregivers do not change the normal daily routines and preferences that are such a large component of a person’s life, and ensure familiarity is supported, for these are the choices that give life its significance.

This strength-based attitude to care is considered a more enabling approach to maintaining and honouring wellbeing in older people.

Additionally, given a person’s care needs may change constantly, we as caregivers must become eternally flexible and adaptable, thus adjust ourselves accordingly, so that we never make any person feel inferior.

Allow frequent rest periods in between every activity to relax, recuperate, and regroup.
Older people get tired, have numerous medical conditions with discomfort associated with them, and when they live with dementia and/or depression, every single task becomes even more exhausting.

Obviously, the more depressed someone is, the more assistance they may require in the short-term, and as the depression is treated, it is likely that person shall show marked improvement regarding their abilities, and the level of independence they may still sustain for themselves.

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Once depression is resolved, then support may be implemented to meet the persons requirements based on a more accurate cognitive and functional assessment, unhampered by depression.

II. Give praise:

We all require praise and encouragement to provide us with those gorgeous warm feelings that come from being needed, appreciated, and valued.

We all know how amazing it feels when someone gives us a random compliment, and how intensely powerful those simple words can be.

When we feel “seen” and “needed”, our self-worth improves dramatically, and this essentially may alleviate feelings of despondency and hopelessness when caring for a person who is depressed.

Every person deserves to feel like they are contributing to the world around them, retaining a sense of control and achievement, and to be praised for that involvement.

The changed expressions on the faces, and in the eyes of a person, when asked to “help out” with simple tasks that are familiar and were previously part of their day-to-day life, such as helping to set the table, or to rake up the leaves, is astonishing.

Can any of us really imagine how difficult it must be to lose ability, and/or then have others thoughtlessly remove the remainder of our autonomy.

Consequently, it is critical that when caring for others we cease focusing only on what people can’t do, and focus on what they can, so we may help them retain some pride in themselves and what they may still achieve.
It is critical to identify a person’s strengths for this may compensate for some of their losses.
This attitude builds coping skills that may make it easier to live with the changes that may be occurring physically and cognitively.

It is termed the process of reablement.

III. Know the Person’s Life Story/Meaningful Engagement and Purpose/Choice and Preference/Lifestyle:

Respect is the basis of upholding the human rights of another, thus it is imperative we appreciate how important it is to listen to people and acknowledge the dignity associated with honouring choices that incorporate making their own decisions in relation to this final chapter of their story.
This is an integral right we cannot remove, and a fundamental component to active and positive ageing.

None of us have the right to remove any facets of what a person has chosen throughout their lives to nourish their sense of self, just because we falsely believe that we know better than the person, what works for them.
This is NOT acting in that person’s best interests but is in fact, neglecting those interests.

Conducting a thorough investigation into a person’s life story, and exploring every feature related to their life transitions, is not only fascinating, but ensures that as caregivers we are given the opportunity to translate everything that is meaningful to that person into their life within residential aged care.
Celebrating their uniqueness is how we ensure the continuation of life for that person.

When we discuss meaningful activity, this represents only that which is meaningful to the specific individual.
It is not what we ‘think’ is meaningful to the person, or what is meaningful to us, but what is meaningful to them.
This approach ensures we maintain personhood and the place a person holds within the world, thus recognising their diversity by supporting and generating person-centred approaches to care.

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Speaking to the person, their family, and possibly their friends, allows us to identify the myriad of area’s that may potentially be most successful in assisting a person to rise from the depths of depression and keep them engaged, and live with a sense of wellbeing.

Enquire and learn about their narrative, family, favorite food, hobbies, career, preferred entertainment, interests, creative outlets, and choices, so this can be threaded into their new world.
Ask about their social, emotional, cultural, spiritual, religious, and sexual needs/need for companionship, so you may discover what gives that person’s life its worth and purpose.

Introducing lifestyle activity that has always been enjoyed by that person is always going to be constructive, however we must be mindful that we may need to simplify these activities if the person is unable to manage them as they did prior to depression and/or living with dementia.
This is no way means we stop those interests but tweak them so they are manageable.

Ensure, also, when presenting any experience that the person may benefit from, that all care staff understand the complexities associated with multiple combinations of noise, and how this may often exacerbate confusion, turmoil, and distress.

Most of us have the capacity to zone ‘white noise’ out a lot of the time, and thus may not realise how bombarding and over-stimulating a person who is depressed, exhibiting low mood and lives with a lowered stress threshold, may become an unpleasant and intimidating experience.

Always ensure common areas are not fraught with a hectic mixture of background noise, clattering dishes, trolleys, loud staff and resident voices, activities in one corner, the cleaner vacuuming in the hallway, radios, and/or the TV blaring in another section, all at the same time,
This may easily trigger anxiety and agitative responses and become the catalyst to a person never wanting to venture out of their room, hence contributing to further isolation and social withdrawal.

Physical exercise is known to have countless positives.
It may be difficult to prompt someone who is particularly withdrawn to exercise, however it is possible to initiate passive exercise slowly in the privacy of a person’s own room.
Caregivers may then transition into suggesting a small stroll, or a walk in a garden, and gradually, as the person improves, more physical and active exercise may be introduced.

The incredible elements associated with exercise are, immediately after a session, people usually feel uplifted, energized, and happy.
The benefits may be quite astounding once those endorphins rush through, and this not only improves mental health and wellbeing, but builds strength, muscle tone, balance, and flexibility.

Exercise does not have to be exhausting and unattainable; it can be completed at a person’s own pace and may be adjusted to their physical and cognitive ability.

Keeping active in body, mind and soul therefore includes relating to the person, whilst maintaining personhood as an expression of the human spirit.
This respect for personal choice, values, beliefs and worth, allows meaningful continuity of life and community.

IV. Sensory stimulation:

The senses love to be stimulated, and a person living with dementia continues to link into and embrace the sensory experience, just as they always have throughout their life.
In fact, it could be suggested that the senses are a key component to whether a person lives a life full of pleasure and fulfilment, or not.

The stimulation of the senses may also evoke connections that delve into past memories of an individual and recreate feelings of happy carefree times.

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Therapeutic interventions, or just the beauty of normal day to day life, contain a plethora of gloriousness that may stimulate us all positively if we only took notice and understood how closely connected to our mood these simple factors are.

It is logical to examine the overwhelming benefits associated with beautiful colours, aromatherapy, massage, dance, cuddling a pet, eating your favourite chocolate, feeling the sun on your face, smelling delectable food cooking, or listening to your favourite tunes.

These natural and alternative influences should never be removed or stripped from a person’s existence, but utilised, so they may continue being aroused and delighted.

This may then play an ongoing and significant part in the maintaining of wellbeing, physical health, and sense of self.

It’s important to be aware that over time, the cognitive perceptions associated with all 5 senses may differ for some people living with dementia, however, this does not mean the ability to “respond” favourably through the
senses disappears in any way.
The way information is processed may change but this does not negate the benefits related to sensory stimulation, nor should we make subjective assumptions that incorrectly suggest that living with dementia removes the ability to “feel” pleasure.

Normal aging processes have more of a dramatic impact on the deterioration of the senses than dementia, so we should essentially consider this as pertinent, when developing engaging environments which enable people to live their best lives and thrive.

Imagine living in a world where all the colour, music, smiles, silky materials, fluffy jumpers, and hugs were removed, and your world was stripped bare????
Imagine the boredom, lethargy, and despondency this may cause???
Imagine how YOU would feel if you were expected to live in a world barren of all sensory stimulation.

Would this not trigger such overwhelming hopelessness and misery, that you may become mad with despair and core suffering???
Would it not be so tedious and mind numbing that it completely affects your temperament, snuffing out the spark that flickers desperately to keep you alive??

If we truly acknowledge how a person living with dementia retains many existing capabilities and challenge ourselves by examining the truth through the lens of curiosity, we may further understand and choose to support and convey care for others in ways that make more sense to them.

These changes in perspective may avoid the unfair marginalisation, and rigid cognitive attitudes that for too long have plagued people living with dementia.
This viewpoint expands our ability in recognising what is required to enhance lives by setting realistic goals that focus on converting a sense of ill-being to one of wellbeing, whilst giving the person living with dementia a greater sense of worth within an existence that is personally significant.

Sensory stimulation is therefore an extremely crucial area of care, that must be embraced and delivered when ensuring a person living with dementia has their needs effectively met in every way.

Colour is a remarkable means of stimulating someone through the introduction of bright, bold colours and may instantly uplift someone in a manner that inspires positive reactions such as happiness and delight.
Imagine looking at a rainbow, as opposed to a puddle, and the difference in the feelings that it arouses.
Imagine beautifully coloured feature walls as opposed to beige.

Which would make you ‘feel’ that heavenly delight that only some colours summon?

Touch we have discussed in communication and thus understand how beneficial it can be.
Many people, love to look at and similarly ‘feel’ the sensation associated with different textures.
Incorporating shiny, smooth, silky, fluffy wall hangings, ribbons, or memory boxes full of surprises, boards of nuts and bolts, dried flowers, and squishy objects, means that even when going for a stroll, everything in a person’s view may be interpretated as an exhilarating and tactile experience.

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These simple but wonderful interventions may be the catalyst to enriching a person’s life simply by reaching into their happy place through the power of caressing, stroking, and physical touch.

Beautiful aromatherapy, with delicious and mouth-watering cooking odours from the kitchen, often stimulate smell, especially when these smells are associated with past positive memories.
The smell of freshly baked bread may be all it takes to enhance mood, and additionally opens the door for reminiscing, and interaction.

Taste can be closely associated to smell.
I recall many of the ladies I cared for sitting in the dining room, making shortbreads, and decorating cupcakes, whilst tasting everything, and conversing cheerfully over their bowls.
When licking the wooden spoons, memories would often be triggered, and together they would relive happy, carefree times that boosted positive feelings linked to self-worth and inclusivity.

Hearing is a sense that is stimulated within the realms of effective communication, music, singing, old movies, the tinkling of water in a fountain, birds chirping, conversation, and laughter, so should be explored in every way.

“When we contemplate music as a feature of a person’s personality and recall, we appreciate the sensory stimulation and beautiful therapeutic effects and response it arouses.
The benefits aren’t unexpected, given this form of therapeutic encounter has been utilised for people living with dementia for countless years, and research supports the corporeal joyfulness, and utter bliss that music inspires, as it takes us on a person’s melodic journey.

It’s an illuminating therapy when used correctly and the individual, specific choices and preferences of the person are honoured.
Keeping active through music maintains physical and cognitive ability and strength for longer, which in turn allows independence to be retained for longer.

The most pertinent benefit of music is the social interaction it can stimulate, thus fostering improved communication, empowering people to express themselves non-verbally through melody and dance.
Music seems to touch the soul of us all.
I have witnessed myself, people who rarely verbalise or speak, break out into song, word perfect, due to relating to their own innate musical appreciation, and connecting into their long-term memory.

Some people will clap and smile and harmonise.
You may see an unexpected little boogie or dance, or a person may kick up their heels, remembering the exquisiteness and loveliness of life through song.
It’s a moving, dazzling, glorious encounter, when used appropriately and cathartically, whilst the distinct predilections of the person are honoured through this alluring medium”. (Bisiani, 2017).

My vision of inciting all 5 senses simultaneously came to fruition when, many years ago, I designed and created the glorious, fantastic, purple, and silver spangled “Stardust Cinema” for all my residents.
I witnessed, firsthand, the breathtaking transformation that resulted from simply committing to the provision of joy, wonder, and delight.

It was one of the most rewarding and touching experiences I have ever observed.
Every single person (all living with advanced dementia) were enthralled, avidly watched with glee, the massive screen that was lavishly draped with lush purple curtains, whilst the old projector whirred in the background, presenting static but stunning images from lost moments in time.
It was truly a sight to behold watching them all lounge back on the velvety purple cushioned movie seats, faded posters reprinted of recognisable old movies and old movie stars hanging on the walls, ensconced within the royal purple darkened room decorated with silver stars, munching with dreamy contentment on fresh popcorn, lollies, and choc tops.
Magical!!!

Each day we move about in space and time, relating to visual, auditory, tactile, olfactory, and verbal stimulus, giving us resources to express ourselves, and give meaning to how this sustains our quality of live.

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When we raise our own awareness to the provisional amazing advantages of sensory stimulation, we may then ensure living environments and lifestyle for people living with dementia do not ever again fall into the realms of dull, depressing, and bland,

Return theses infinitely beautiful wonders to the world of a person living with dementia and see them blossom and flourish.
The senses are yet another doorway to wellbeing, so I implore you all to open your arms wide to the never-ending possibilities of sensory stimulation.

V. Nostalgia/reminiscence:

Sitting with a person and talking about their life, getting to know them, gaining insight into who they are, and actively engaging and immersing yourself in their lives, may generate special bonds and rapport and develop precious relationships; but moreover arouse feelings akin to comfort and security, leading to a sense of belonging, raised self- esteem and wellbeing.

It has been said that the best learning experiences are at the feet of an older person.

Recognising the evolution of a person throughout their own splendid journey and divergent life transitions, allows us to honour their humanity, retaining those wonderful elements required to enable us to cultivate compassion by learning to respect and value others.

We cannot deny how these myriads of experiences contribute to a lifetime of development and must ensure these aspects of a person’s spirit are always retained.

“Reminiscence and validation are both a powerful and fascinating technique used when acting compassionately and initiating positive interaction.
Through the precious, poignant beauty of nostalgia we may empathetically capture the essence of a person, whilst linking and validating their long-term passions, sentiments, and memories, to the present moment.

The use of old, faded, photographs that may curl at the edges, hold moments in time for eternity.
Sentimental possessions and little trinkets may all generate contact and interaction on a level that does not only rely on verbal interaction”. (Bisiani, 2017).

Anything can be shared if only we showed some interest. VI. Environment:

When establishing a home for a person who is depressed and living with dementia, it is necessary to be aware that the built environment plays a major factor in how someone feels, given we all rely on many aspects of our environment to provide much needed solace and peace.
Much of how we think about ourselves is also reflected in our environment, thus it is widely recognized that the built environment may have a significant positive or negative affect on a person living with dementia.

For people living with dementia, their physical and social environments may become more difficult to navigate with changes in cognition.
A dementia-enabling environment helps a person living with dementia reach their full potential and does not cause needless disability and may help them hold on to their world by maintaining ties with familiar and comfortable surroundings.

There are two types of living environments.
A ‘demanding’ environment is non supportive of people living with dementia and does not compensate them for their changes in cognition, whereas a ‘therapeutic’ environment is a source of treatment as it enhances rather than neglects remaining abilities.

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A well-set-up care environment:

• compensates for reduced sensory, cognitive, and motor ability.
• supports independence/abilities.
• keeps health at the best possible level.
• provides familiarity.
• promotes inclusiveness/involvement.
• provides meaningful engagement and relationships.
• provides a sense of wellbeing.
• supports continuation of roles and lifestyles.
• allows easy access and wayfinding.
• respects the right to freedom of choice.
• respects privacy, and dignity.
• promotes safety, security, and comfort. Aged care environments may be daunting and tough to navigate, and subsequently a person who is depressed is most likely not going to bother moving at all, because it takes too long, and requires too much effort.
  Thus, small comfortable, cozy, homelike spaces are ideal. A residents’ room is their special haven and retreat, thus must feel like home.
  Advised, is setting the persons room up prior to admission, with all their personal and sentimental items, to make it as familiar as possible, with recognisable fittings and furnishings.
  Transitioning into aged care may be exceptionally traumatic and quite terrifying given how alien and unfamiliar the environment can be, so imagine how reassuring it would feel to enter a room that made you feel like you were at home. Family photos are wonderful, especially if named, and are fantastic for initiating conversations.
  As are favourite pictures, an old crystal cabinet, memorabilia, an old favourite chair, or a throw rug on the bed. Enabling environments are therefore a central aspect of care, and support, health and well-being for people living with dementia, allowing them to feel valued as an individual by providing them with a sense of normality that sustains their quality of life.
  By supporting the validity of environmental design, we maximise awareness and orientation, promote feelings of safety and security, provide opportunities for significant social contact, and support functional ability through meaningful activity. ******* Consequently, these interventions, plus more, may potentially be effective in reducing or resolving depression in the life of a person living with dementia. This is not an exhaustive list, since it is impossible to work via a generic, textbook scenario, because every single person will always present differently because of who they are. The goals of care should always therefore be developed to enable a person to live their best life through individualised approaches that are tailored towards their personal needs, choices, and preferences. Once depression has been resolved, it may then be possible to identify if the causes of the cognitive/functional and physical disability have resulted from living with depression only, or through living with dementia AND depression. If the person is not exhibiting any cognitive changes once depression has been resolved, then it is possible to assume that dementia is not apparent, and a misdiagnosis may have occurred. Use of the MMSE at this stage is advisable.

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Results:

When examining the results of the data collection, it was possible to evaluate the figures and unequivocally state that the positive benefits and effects of the processes used in identifying and treating depression in residents living with dementia, was highly successful.

Within a 12-month time frame the following was identified:

• 26 out of 38 residents living with dementia had an undiagnosed depression in some form at the commencement of the research.
• Out of the 24 who were diagnosed with depression, there were 9 with chronic moderate to severe depression.
• Only 3 residents had already been diagnosed depression by a geriatrician and were receiving active treatment.
• Depression had not been previously diagnosed or recognised in the remaining 23 residents.
• 12 months later, 23 out of the 26 residents no longer had a current diagnosis of depression.
• 12 months later 3 out of the 26 residents were living with mild depression, however ongoing treatment managing their depression actively.
• Deprescribing of all psychotropics, except in the cases of residents with diagnosed mental health conditions, where they required the prescribed use of these medications.
• 4 out of the 26 residents returned to their previous full cognitive level of functioning post interventions.
  * Thus, it seems apparent they may have been misdiagnosed with a diagnosis of dementia, and instead had been living with an undiagnosed and undetected chronic severe depression. * There were further noteworthy benefits apparent in 92% of the pilot group:

• A significant improvement in mini-mental cognitive scores/results between 3-14 points, depending on the type of dementia and the progression.
• Reduction and elimination of all changed and stress related behavioural responses that were displayed as a result of unmet need.
• Marked increased intake, (hydration and dietary) and regained enjoyment associated with the dining experience.
• Overall healthy weight range and BMI for all residents was achieved.
• Increased participation in lifestyle activity, engaging socially with others, initiating conversations, and improved interaction.
• Improved functional ability, mobility, and transfer ability.
• Reduction in falls and serious fall related injury by 2/3 in 12 months.
• Improved skin integrity.
• Enhanced productive sleep.
• Maximised independence and quality of life. Conclusion: From the above study, it has been possible to examine the incidence of undiagnosed and untreated depression in people living with dementia residing in RACF’s and demonstrate the impact this has on life quality, whilst highlighting the distressing fact that occasional misdiagnosis of dementia as a primary diagnosis may occur.
  This statement requires an acknowledgment by all health care professionals, regarding the dangers associated with not recognising depression as a serious problem that needs urgent resolution. With more efficient assessment techniques, commenced at the onset of admission, and continued regularly, it is possible to not only identify the prevalence of depression, but to treat it effectively. Prevention and treatment of depression allows us to delve into more precise scrutiny of a person’s individual needs, incorporating and facilitating more accuracy in assessing their pre-morbid, functional, physical, cognitive, and biopsychosocial needs, so that we may undertake and facilitate a pathway that enables personalised care to be developed and implemented, promoting maximized quality of life.

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The alternative is a dark and despairing scenario, where a person may be sentenced to living the remainder of their life with both dementia and depression, enabling the insidious nature of the depression to constantly mask and destroy their true presentation, providing false information for care to be based upon.

Instead, we should be committed to creating a profound difference to enriching the lives of people living with dementia, value each person’s voice, and implement inspiring, respectful, and meaningful life experiences that empower and unite people living with dementia to live their best lives.

It is crucial that, as caregivers, we recognize the dangerous battle that occurs when depression fights for superiority over dementia, and callously strips a person of their future.

Furthermore, it is imperative that as a community we rid ourselves of our subjective assumptions associated with dementia and realise that dementia does not mean losing oneself in any way or form.
A person will only lose oneself if we allow DEPRESSION to win this war!!!!

Copyright. 2005: Leah Bisiani – MHlthSc/DipBus/RN1/Aged Care and Dementia Consultant Reviewed.2023.

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