When we hear the term “Alzheimer’s,” the mind instantaneously jumps to memory loss—forgetfulness of names, faces, and even, eventually, one’s own self. But anyone who has lived this process with a loved one will tell you that the actual image is a good deal more complex. Alzheimer’s is a neurologic disease, certainly, but it is also highly emotional, even frequently deeply psychological. In its wake, many elders quietly carry around depression, anxiety, and sometimes psychosis—mental conditions that can bemasked, misunderstood, and left untreated. These comorbidities don’t just tag along with Alzheimer’s; they set the lived reality of it, coloring daily life with emotional tones that need to demand our full attention.
It is estimated that nearly 90% of people living with dementia will experience some form of psychiatric symptom over the course of their illness. But these aren’t simply side effects or coincidences. Whether it’s a persistent sadness, mounting worry, or distorted perceptions, these emotional experiences influence how a person relates to their world—and how their world relates back to them.
Depression: The quiet weight
One of the most common co-morbidities is depression. Depression commonly co-occurs with dementia due to shared neurobiological changes, such as hippocampal atrophy, disrupted serotonin pathways, and chronic neuroinflammation, which affects both mood and cognition. In elders with Alzheimer’s disease, this emotional weight can be particularly severe, but usually, it is unspoken. In contrast to typical depression, in which an individual may verbally convey hopelessness or suicidal tendencies, in such cases, the indicators may be more subdued. You may find a loved one pulling away from activities they used to like, being excessively cranky, or just appearing flat and apathetic. Depression’s language alters when cognition and memory are compromised—it manifests itself more through actions than speech.
A keen, empathetic eye is needed to detect depression in a person with Alzheimer’s. Relatives and caregivers most frequently recognise that something more profound is happening beyond forgetfulness. When a person no longer brightens up to their favorite music or becomes withdrawn in a room full of people they know, it is important to consider—are they losing memories, or are they feeling invisible and unheard?
Diagnosis, particularly in the early phases, requires tools that can measure emotional well-being in terms adapted to cognitive capacity. But aside from tests and checklists, actual diagnosis most often starts with observation by others who are familiar with the individual, who can feel the difference between a quiet afternoon and a prolonged melancholy.
When it comes to treatment, pharmacological support may be considered when necessary, but it should never be the first or only step. The emotional life of someone with Alzheimer’s is sensitive, often fragile, and deserves an approach that values warmth and trust. Gentle conversations, tailored routines, access to familiar memories and faces—all of these can serve as powerful antidotes to isolation. Structured engagement, whether through reminiscence therapy, art, music, or simply the comfort of companionship, can help rekindle a spark that seemed long extinguished.
Anxiety: The unseen tension
Anxiety in dementia is often linked to degeneration in brain regions like the amygdala and prefrontal cortex, which regulate fear and emotional control, along with disruptions in neurotransmitters like GABA and serotonin. Where depression can manifest as withdrawal, anxiety is likely to manifest as restlessness. It’s the pacing down the corridor, the constant questioning, and the nervous looks at the clock. People with Alzheimer’s may not be able to put their fears into words, but their body and behavior shout it out. Anxiety can manifest in the most unsuspecting ways—irritability, agitation, or a greater need for reassurance. And yet it is one of the most under-represented phenomena in dementia care.
Dementia anxiety does not necessarily conform to type. You may not hear someone declare, “I’m afraid,” but you may see him or her hold tight to routines, declare confusion in new environments, or respond with agitation when removed from known individuals. His or her fear can stem from the disorientation inherent in memory loss—a world where time is malleable and certainty is fleeting. The difficulty is in accepting these signs for what they are: not merely behavioral problems or “part of the disease,” but demonstrations of inner distress. Diagnosis again depends heavily upon caregivers’ and family members’ intuition. No checklist can substitute for the knowledge that results from day-to-day interaction—the knowing glance that says, “Something’s not right.” Treatment must also be done carefully. Pharmacological interventions might be added with extreme caution, always weighed against the possibility of side effects. But like depression, it is usually the setting and human relationship that holds the solution. Peaceful, ordered routine, gentle voice, familiar environment, and purposeful activities can offer a feeling of safety and predictability that soothes the mind. When anxiety is responded to with reassurance rather than correction, with empathy rather than frustration, the effect can be life-changing.
Psychosis: The fractured lens
In some cases, Alzheimer’s disease brings with it more distressing symptoms— delusions and hallucinations that blur the line between reality and imagination. A senior may believe that someone is stealing from them, or that a loved one has been replaced by an impostor. They may see things that others cannot see—shadows at the window, children in the room, or unfamiliar figures moving through familiar spaces. These experiences are not “madness,” as society once cruelly labelled them. They are signs of a brain struggling to make sense of a changing world, to fill in the gaps where memory and logic used to reside. And for the person experiencing them, these moments feel vividly real. To dismiss them, or worse, to scold, is to deny the reality they are living in.
Psychosis in dementia has to be treated with care and sensitivity. There are drug options, but they are fraught with serious risks and should only be employed when the safety of the elderly or others is at stake. Caregivers, however, may be the finest line of defense—learning to redirect instead of countermand, comfort instead of confront. Minor adjustments in lighting, noise, and routine can decrease sensory overload and calm confusion. Sometimes, simply holding a hand and saying, “You’re safe,” can make all the difference.
Seeing the Person Beyond the Symptoms
At the heart of this conversation is a simple truth: emotional well-being is not separate from dementia care; it is central to it. When we look past the diagnosis and see the person, truly see them, we begin to understand how vital it is to address depression, anxiety, and psychosis not as side notes, but as core parts of their experience.
To love someone with Alzheimer’s is to walk alongside them through a changing landscape—one where memories may fade, but emotions often remain vivid and raw. It requires us to listen with our hearts, to respond with patience, and to care not just for their needs, but for their inner life.
Diagnosis and treatment, whether clinical or compassionate, must begin with this understanding. The person with dementia is still there—still feeling, still needing, still worthy of joy and connection. And in recognising the emotional complexities of their journey, we honour not just their memory, but their humanity.
When comorbidities such as depression, anxiety, or psychosis interfere with a person’s compliance with care or daily routines, they can lead to distress and significant health escalations. This is why, in such cases, careful pharmacological intervention becomes essential—not just to manage symptoms, but to restore stability.
(The author, Neha Sinha, is a Dementia Specialist, CEO & Co-founder, of Epoch Elder Care.)
