ACADEMIA Letters

Evaluating Obsessive-Compulsive Symptoms in Dementia

Patients
Eda Gorbis, The Westwood Institute for Anxiety Disorders
Rebecca Braverman, The Westwood Institute for Anxiety Disorders

Patients with dementia and patients with OCD can often present similar symptoms. However,
the source of their cognitive impairments are different and thus require different treatments.
Therefore, an accurate assessment of the cause of these cognitive issues is paramount to treat-
ment in therapy.
Obsessive-Compulsive Disorder is defined by the DSM-V (APA, 2013) as a neurological
disorder in which an individual will perform a series of ritualistic behaviors or compulsions
in response to persistent and unwanted intrusive thoughts or obsessions. Many experts and
researchers consider OCD to be a syndrome because it encompasses comorbidities such as
depression, generalized anxiety, panic disorder, eating disorders, and others. Due to the neu-
ropsychological nature of the disorder, it may also represent underlying physiological issues
within the brain. In evaluating maladaptive behaviors, it is key to identify whether the ac-
tions are impulsive or compulsive. (Moheb et al., 2019) If a behavior is compulsive or “ego-
dystonic,” it is separated from the individual’s beliefs and core values. For example, a patient
can understand that flipping a lightswitch on and off in multiples of three will not prevent bad
things from happening to them, but they feel they have no choice to not perform this task.
Conversely, an impulsive behavior is “ego-syntonic” when a behavior is reflective of a per-
son’s beliefs and core values. Impulsive behaviors are about instant gratification with time
for reflection at a later date. People with impulsive behaviors rarely have the levels of insight
of those with compulsive behaviors, which makes treatment more difficult for the patient be-
cause behavioral adjustments equates to a value adjustment. This is why the identification of
behaviors as ego-dystonic or ego-syntonic is crucial for diagnosis and treatment.
Dementia, according to the DSM-V, is a neurological disorder which manifests itself in the

Academia Letters, June 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Eda Gorbis, thewestwoodinstitute@gmail.com

Citation: Gorbis, E., Braverman, R. (2021). Evaluating Obsessive-Compulsive Symptoms in Dementia
Patients. Academia Letters, Article 1272. https://doi.org/10.20935/AL1272.

1
deterioration of the prefrontal and temporal lobes of the brain. This results in the degeneration
of executive functioning including memory loss, language loss, attention span, and problem
solving.. While there is no one cause of dementia, the disorder usually appears during the
later decades of a person’s life, but is outside of the typical aging process. (Nifli, 2017; CDC,
2019) Dementia is a condition for several memory disorders including Alzheimer’s Disease,
Mild Cognitive Impairment, Vascular Diseases, and brain traumas.
Within the last twenty years, case studies and literature reviews have argued for new con-
nections between OCD and dementia. A literature review by Greisberg & McKay (2003) of
fourteen studies on the neurophysiology of OCD revealed memory related deficits in patients
with OCD. Of the fourteen studies focusing on executive and attentional functioning, two
studies found those with OCD had significant impairments in executive functioning and visu-
ospatial memory, five studies found those with OCD had significant motor function impair-
ments, and two studies found significant linguistic impairments and slowness when correcting
mistakes, which are some of the similar symptoms presented in dementia patients.
In addition to similar symptoms, it has been noted that the neurology of the brains of pa-
tients of the two disorders are similar. In a 2012 study, when observing groups of patients with
Frontotemporal Dementia (FTD), nine out of eleven patients were reported by their caregivers
to show obsessive and compulsive behaviors in a hospital setting but were not diagnosed with
OCD. Some of the most common compulsions reported were checking, ordering/arranging,
repeating rituals, and cleaning. (Perry et al., 2012) This supports the findings of case studies
conducted by Frileux, S., Millet, B., & Fossati, P. (2020), which examined late-onset OCD
in patients diagnosed with Dementia with Lewy Bodies (DLB). The two case studies exam-
ined by these researchers found these patients were initially treatment-resistant, but were later
successfully treated with medication and full-time hospitalization.
There are a few key behavioral differences between OCD and dementia. Preliminarily, the
checking behaviors done by patients with dementia are related to memory loss and forgetful-
ness, whereas checking behaviors done in OCD are due to the intense need to alleviate anxiety
and the inability to deal with uncertainty. Dementia patients also do not experience intrusive
thoughts to the same degree as OCD patients. For those with OCD, the intrusive thoughts
are consistent and debilitating, resulting in the need to perform compulsions. They are also
recognized as ego-dystonic and unwanted by the patient. These thoughts, which can be highly
distressing, are not reflective of the patient’s behavior or core values. Another key distinction
is the age of onset. Dementia typically develops around the age of sixty-five, whereas OCD
typically develops during middle-childhood or adolescence. Late-onset OCD development
beyond the age of thirty-five years old is rare and may be attributable to other undiagnosed
physiological conditions or disorders.

Academia Letters, June 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Eda Gorbis, thewestwoodinstitute@gmail.com

Citation: Gorbis, E., Braverman, R. (2021). Evaluating Obsessive-Compulsive Symptoms in Dementia
Patients. Academia Letters, Article 1272. https://doi.org/10.20935/AL1272.

2
 A well-informed and evidence-based diagnosis is critical for the projected success of treat-
ment. Using the proper tools and assessments, as well as patient history given by either the
patient or by their caregiver is an important part of the process. If a patient has a history of
obsessive-compulsive behaviors that predate any memory or executive functioning issues, it
is likely that the two disorders are not correlated. It is possible for a patient with OCD to
develop dementia later in life, but it is not a predictor of the development of memory-related
disorders. Assessments for OCD include The Yale-Brown Obsessive-Compulsive Scale or
YBOCS-II, the Obsessive-Compulsive Inventory- Revised (OCI-R) and the Hamilton Anxi-
ety scale do not take memory or executive functioning into account, which means that it can
be difficult to differentiate compulsions from other behaviors related to dementia. It is up to
the professional opinion of the clinician assessing the patient to recognize the symptoms of
memory disorders like dementia and Alzheimer’s Disease. If the researcher misses the early
signs of these disorders,the patient could miss the opportunity for treatment. Two assessment
tools that can be used to differentiate between dementia and OCD are the Structured Clinical
Interview for DSM Disorders (SCID) and the Clinical Global Impressions Scale (CGI), (as
seen in a clinical case study by Frydman et al., 2010). These tests can be used across multiple
disorders and dimensions, which makes it easier to discern on the part of the clinician whether
the abnormal behaviors are connected to either or both disorders.
Once the correct diagnosis is made, treatment and relapse prevention is the final step. Like
OCD, dementia currently does not have a fail-safe treatment, but there are some things that can
be done to alleviate cognitive symptoms and memory decline. The gold standard treatment for
OCD, Exposure and Response Prevention (ExRP) is a form of Cognitive-Behavioral Therapy
(CBT) and acts as “entertainment for the doubts.” This kind of therapy requires compliance
on the part of the patient, which makes treatment for comorbid dementia especially difficult.
Instead, as in the Perry et al. (2012) study, clinicians and researchers may have to rely on the
word of a patient’s caregiver, which may be a family member or legally appointed guardian, in
order to complete the proper assessments and follow treatment guidelines. Instead of ExRP,
the dementia patient would most likely need a regimen of medication and rigorous cognitive
stimulation activities overseen by a team of clinicians in order to change behaviors. The Uni-
versity of California: Los Angeles Longevity Center offers Memory Training sessions, which
can improve linguistic memory and spatial memory through activities like language classes,
tango lessons, and piano lessons. Unfortunately, this can only be used for patients with an
early diagnosis and does not address comorbid disorders.
Dementia with OCD as a comorbidity presents the patient and the clinician with treat-
ment and life-improvement challenges. By using the proper assessment tools to differentiate
between these two conditions, and then identify comorbidities, the clinician can create the

Academia Letters, June 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Eda Gorbis, thewestwoodinstitute@gmail.com

Citation: Gorbis, E., Braverman, R. (2021). Evaluating Obsessive-Compulsive Symptoms in Dementia
Patients. Academia Letters, Article 1272. https://doi.org/10.20935/AL1272.

3
appropriate medical, behavioral, and pharmacological protocol. This will increase the prob-
ability of a successful therapeutic treatment plan for the patient.
For more information on research concerning OCD and dementia, please contact the West-
wood Institute for Anxiety Disorders in Los Angeles, CA at our website: www.hope4ocd.
c or email us at thewestwoodinstitute@gmail.co. Additional resources such as the UCLA
Longevity Center can be reached at sgoldfarb@mednet.ucla.e or by calling (310) 794-0680.
Special thanks to Rebecca Braverman and Alexander Gorbis for their assistance.
Note: This article was originally published for the International OCD Foundation summer
2021 newsletter.

References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental dis-
orders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

C. (2019, April 05). What Is Dementia? Retrieved January 09, 2021, from https://www.cdc.
gov/aging/dementia/index.html

Frydman, I., Ferreira-Garcia, R., Borges, M. C., Velakoulis, D., Walterfang, M., & Fontenelle,
L. F. (2010). Dementia developing in late-onset and treatment-refractory obsessive-compulsive
disorder. Cognitive and behavioral neurology, 23(3), 205-208.

Frileux, S., Millet, B., & Fossati, P. (2020). Late-Onset OCD as a Potential Harbinger of
Dementia With Lewy Bodies: A Report of Two Cases. Frontiers in psychiatry, 11, 554.

Greisberg, S., & McKay, D. (2003). Neuropsychology of obsessive-compulsive disorder: a

review and treatment implications. Clinical Psychology Review, 23(1), 95-117.

Moheb, N., Charuworn, K., Ashla, M. M., Desarzant, R., Chavez, D., & Mendez, M. F.
(2019). Repetitive behaviors in frontotemporal dementia: compulsions or impulsions?.
The Journal of neuropsychiatry and clinical neurosciences, 31(2), 132-136.

Nifli, A. P. (2017). The neurobiology of dementia: spatial and temporal dynamics of Alzheimer’s
disease major biomarkers. HELLENIC JOURNAL OF NUCLEAR MEDICINE, 20(2), 91-
103.

Perry, D. C., Whitwell, J. L., Boeve, B. F., Pankratz, V. S., Knopman, D. S., Petersen,
R. C.,…& Josephs, K. A. (2012). Voxel‐based morphometry in patients with obses-

Academia Letters, June 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Eda Gorbis, thewestwoodinstitute@gmail.com

Citation: Gorbis, E., Braverman, R. (2021). Evaluating Obsessive-Compulsive Symptoms in Dementia
Patients. Academia Letters, Article 1272. https://doi.org/10.20935/AL1272.

4
 sive‐compulsive behaviors in behavioral variant frontotemporal dementia. European jour-
nal of neurology, 19(6), 911-917.

Academia Letters, June 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Eda Gorbis, thewestwoodinstitute@gmail.com

Citation: Gorbis, E., Braverman, R. (2021). Evaluating Obsessive-Compulsive Symptoms in Dementia
Patients. Academia Letters, Article 1272. https://doi.org/10.20935/AL1272.