The feeling of anxiety is a fairly common experience of all people. It can be normal – functional, or pathological – dysfunctional and it sometimes reaches a level of disorder. Anxiety coexists in many mental disorders. It is characterized by a sense of imminent danger and is accompanied by physical manifestations. Signs and symptoms that may be experienced when a person is in a state of anxiety are terror, muscle cramps, headache, muscle tension, feeling of instability, shortness of breath, hyperventilation, fatigue, hyperactivity of the autonomic nervous system (flushing, pallor, tachycardia, palpitations, sweating, cold hands and feet, diarrhea, dry mouth), numbness, feelings of intense fear, difficulty in concentration, hypervigilance, insomnia, decreased libido, “lump in the throat” feeling, and nausea or stomach tightness. In the DSM -IV-TR taxonomic system, the following anxiety disorders are included: panic disorder with or without agoraphobia, agoraphobia without a history of panic disorder, specific and social phobias, obsessive compulsive disorder, post-traumatic stress disorder, acute stress disorder, generalized anxiety disorder, anxiety due to a general physical condition, anxiety caused by substance use and anxiety not otherwise specified.
Until recently, particular attention to the anxiety in people suffering from dementia had not been given. However, research has shown that anxiety is very common in this population. It seems that anxiety may be more common in people with a cognitive impairment compared to mentally healthy patients. The literature suggests that the prevalence of anxiety disorders in dementia patients ranges from 5% to 21% with most frequent disorder, the generalized anxiety disorder. Additionally, it is reported that the prevalence of anxiety symptoms in this population ranges from 25% to 70% and appears to be the same in mild and moderate dementia, but lower in severe dementia. Patients with vascular dementia are more likely to encounter anxiety problems compared to patients with Alzheimer’s disease.
Comorbidity of anxiety and dementia is associated with an underactivity in daily activities, with a need for increased care by others, with more cognitive deficits, with more intense behaviour disorders, with more frequent problems in the caregiver-patient relationship and with a poorer quality of life compared to simple dementia.
The recognition of anxiety in people with dementia is difficult because of the coating of cognitive, depressive and anxiety symptoms, such as, poor concentration, fatigue, irritability, and inability to relax, and, also, because of the difficulty these patients often have in precisely describing the symptoms of anxiety. The comprehensive psychiatric interview in which information is obtained from both the sufferer and their carers and the use of structured interviews and anxiety rating scales are particularly useful tools in identifying anxiety symptoms.
In a study involving 41 patients with mild and moderate dementia and their carers, where both caregivers and patients completed separately two anxiety scales each and underwent a structured diagnostic interview for anxiety, it was found that, although the caregivers tended to slightly overestimate the intensity of symptoms compared to the patients, the information was reliable from both groups and what the authors of this article suggested was that the information from the carers to be used as a supplement and not as a substitute for the information gathered from the patients.
Particular interest appears in the results of several studies that argue that anxiety is a risk factor, even stronger from depression, for dementia. Specifically, in one of these studies, which involved 400 patients over 65 years old, diagnosed with dementia and other 1353 people as a control group, possible risk factors for dementia were sought through the historical records in primary care. It was found that a previous recorded anxiety diagnosis increased by 2.76 times the risk of developing dementia and a previous recorded depression diagnosis increased the risk by 2.19 times.
As far as the treatment of anxiety symptoms in dementia is concerned, both psychosocial and pharmaceutical therapies are suggested. Typically, the clinical guidelines recommend initial use of psychosocial treatments before the use of drug therapy to avoid possible side effects from the use of drugs. Psychosocial interventions could be classified into four categories: emotion-oriented therapies (where the use of memories, simulating presence therapy and validation therapies are found), short-term psychotherapies (including behavioural and cognitive-behavioural psychotherapy), sensory stimulation treatments (including engagement treatments with activities and exercise, aromatherapy, music therapy, etc.) and a new category, personalized or person-centred psychosocial interventions where we find a combination of treatments according to each case and sometimes medication is concomitantly prescribed. The main objective of emotion-oriented therapies is to adapt the treatment to emotional needs of the person with dementia, with the aim of improving the quality of their life, their social functioning, and their ability to address the cognitive, emotional and social consequences of the disease, as these are noticed by them. With treatments using memories, patients are encouraged to use memory aids of their personal lives, such as family photos and talking about the memories of the past. Validation therapies are based on the acceptance of and response to the feelings of the person with dementia, as a valid response to the person’s perception of reality, rather than trying to redirect them to a common reality. Both behavioural psychotherapy and cognitive psychotherapy have been successfully applied to the treatment of anxiety in dementia. Generally, cognitive behavioural psychotherapy is more effective in people with mild or moderate dementia, while those with more severe dementia respond better to behavioural psychotherapy. A number of behavioural techniques, such as the use of behavioural support, progressive muscle relaxation and training in social skills are tested. Even though clinical observations are generally positive about the effectiveness of sensory stimulation therapies, for most of them, extensive research to verify their effectiveness has not been done. As far as music therapy (usually with the listening method) is concerned, benefits for people with dementia are described through several clinical studies, something that happens in the case of treatments relating to dealing with animals (generally trained dogs), treatments with physical activity and, finally, therapies that have to do with touch, using massage. Generally, the existing data on non-pharmacological interventions in dementia show that treatments with promising therapeutic effects for treating anxiety in dementia are behavioural therapy, cognitive behavioural therapy, music therapy, physical exercise therapies, massage treatments, and treatments relating to dealing with animals. Regarding the drug therapy of anxiety in dementia, the guidelines are generally the same as in the treatment of anxiety in general. Thus, it is possible to use antidepressants, especially from the classes of SSRIs and SNRIs (such as Escitalopram, Paroxetine, Sertraline, Venlafaxine, etc.), Benzodiazepines, Buspirone and Pregabalin. In the case of non-good response to the aforementioned drugs, sometimes antipsychotics, especially from the class of atypical antipsychotics, are used. Particular attention must be paid to possible side effects that may occur from the medication, which often can worsen some of the symptoms of dementia, such as memory disorder.
It seems that anxiety is a very common and aggravating factor in dementia. Early diagnosis and treatment of anxiety and stress may help in preventing future dementia, while it plays an important role in improving the quality of life of patients with dementia.