Q3

How can cognitive dysfunction in patients with depression be easily assessed in routine clinical practice?

Answered by Harry Barry

Depression is a multidimensional disorder involving a combination of physical, emotional and cognitive symptoms. Cognition can be categorised as having affective ‘hot’ and logic-based ‘cold’ components. Many clinicians will identify ‘hot’ cognitions (associated with emotions) in depression, such as shame, anxiety and guilt, but are less likely to identify ‘cold’ cognitive dysfunction. Clinicians are more likely to identify daily functional difficulties, the cause of which may be unrecognised ‘cold’ cognitive dysfunction. The following five simple questions are useful to screen for such functional difficulties and the most likely cognitive domain involved.

  • Do you have difficulties making decisions either at home or work and, if so, why? (Decision making)
  • Do you have difficulties reading newspapers, lecture notes or data at work, or following TV programmes or conversations? (Concentration/attention)
  • Do you find yourself misplacing items such as keys, or have difficulties remembering names or shopping items, or lose track of tasks at home or at work? (Memory)
  • Do you struggle to start or, in particular, finish common tasks, either at home or at work, due to these problems? (Motivation, problem solving, indecision, organisation)
  • How do all of above affect you in your day-to-day life? (Consequences of cognitive dysfunction)

Answered by Esther Klag

Through questions put to the patient, the clinician can elicit descriptions of symptoms indicating cognitive dysfunction. However, the aetiology and severity of the cognitive dysfunction are not easily assessed clinically and require careful questioning, observation and clinical judgement.

Some patients suffering with depression will readily describe cognitive difficulties, e.g. older patients concerned about dementia. Most other patients will tend to describe mood disturbance – ‘I’m not myself’ – behavioural difficulties and/or external stressors.
If you are a clinical practitioner who knows your patient, you will, of course, develop hypotheses in terms of changes in functioning but if this is not the case, it is important to ask questions that may reflect cognitive dysfunction. Some of these questions will be direct; others will be more subtle, indirect and often less threatening to the patient.

Direct enquiries can refer to relevant cognitive functions in the domains of attention, working memory, executive function and processing speed.1 (See also Diagnosis and assessment) Indirect enquiries can focus on functioning abilities, habits and quality of life in areas relevant to the patient such as occupational or academic progress, organisation within the home and family, and relationships. All these may be associated with, or reflect, cognitive impairment associated with depression.

Diagnosis and treatment are all the more challenging since various conditions other than depression, as well as co-morbidities, can also affect cognitive functions. Clinical judgement can, of course, be aided by identifying cognitive dysfunction within the specific context of an individual patient’s life (age, profession, background, medical history, etc). A simple, quick initial screening tool would be helpful and the THINC group is working on developing this.

References

 

  1. McIntyre RS, Cha DS, Soczynska JK, Woldeyohannes HO, Gallaugher LA, Kudlow P, Alsuwaidan M, Baskaran A. Cognitive deficits and functional outcomes in major depressive disorder: determinants, substrates, and treatment interventions. Depress Anxiety 2013; 30: 515-527.
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