The benefits of actively assessing and treating anxiety in elderly individuals with dementia

In our last blog post, we reviewed the relationship between depression and dementia. In this post, we will focus on another common behavioral health condition — anxiety.

Prevalence of anxiety symptoms in dementia varies markedly by study, with estimates ranging from 25% to 70% of cases. One challenge in examining the association is the lack of a clear definition of anxiety in dementia, as there is significant overlap in the symptoms of depression, anxiety, agitation, and dementia. A careful review of the overlap by Starkstein et al., however, highlights important factors central to anxiety:5

    • Excessive worry/anxiety that is difficult to control
    • Restlessness
    • Irritability
    • Muscle tension
    • Fears
    • Respiratory symptoms

Presence of anxiety symptoms is additionally associated with diminished quality of life and activities of daily living (ADLs) when compared to dementia without anxiety. However, the relation of dementia progression and anxiety remains somewhat unclear.

What is uncontroversial, however, is that anxiety may have significant negative consequences for both patients and caregivers.2 Tools such as the GAD-7 can alert the physician to the presence and severity of anxiety, as well as providing an easy tool for re-assessment to track response to treatment.

Common treatment options for anxiety

Short term use of benzodiazepines is the most common treatment for anxiety in the general population. However, use in the elderly, particularly the cognitively impaired elderly, is increasingly regarded with caution.3 Over-sedation, with risk of falls and fractures, is a clear concern, as is confusion and cognitive blunting. The relationship between benzodiazepine exposure and subsequent development of dementia is unclear and controversial, with the link suggested and rebutted in a series of publications.4

Nevertheless, the risk profile of benzodiazepines increasingly is leading practitioners to use antidepressants as first-line pharmacologic treatment of anxiety, which as noted has significant overlap with depression. With many antidepressants having additional indications for anxiety, physicians can choose agents based on side effect profiles, capacity to address insomnia, and, more recently, potential cognitive benefits.3

Psychotherapies, particularly those with supportive and relaxation components, are important treatment options during the early stages of cognitive impairment.1

How to assess cognition and behavioral health

Assessment for current behavioral health conditions is an essential addition to the workup of cognitive impairment in the elderly. Untreated anxiety clearly may compromise outcomes, quality of life, and ability to maintain independent living.

BrainCheck can assist the practitioner in assessing current cognition and behavioral health; re-assessment of cognition can play an important role in the evaluation of response to treatment, particularly improvement in mental function in response to de-prescribing.

Our next blog will focus on polypharmacy in the elderly and effects on cognitive health.

References

  1. Andreescu, C., & Varon, D. (2015). New research on anxiety disorders in the elderly and an update on evidence-based treatments. Current Psychiatry Reports, 17(7). https://doi.org/10.1007/s11920-015-0595-8
  2. Breitve, M.H., Hynninen, M.J., Bronnick, K., Chwiszczuk, L.J., Auestad, B.H., Aarsland, D., & Rongve, A. (2016). A longitudinal study of anxiety and cognitive decline in dementia with Lewy bodies and Alzheimer’s disease. Alzheimer’s Research & Therapy, 8(3). https://doi.org/10.1186/s13195-016-0171-4
  3. Crocco, E.A., Jaramillo, S., Cruz-Ortiz, C., & Camfield, K. (2017). Pharmacological management of anxiety disorders in the elderly. Current Treatment Options in Psychiatry, 4(1), 33-46. https://dx.doi.org/10.1007%2Fs40501-017-0102-4
  4. Gray, S.L., Dublin, S., Yu, O., Walker, R., Anderson, M., Hubbard, R.A., Crane, P.K., & Larson, E.B. (2016). Benzodiazepine use and risk of incident dementia or cognitive decline: Prospective population based study. The BMJ, 352(i90). https://doi.org/10.1136/bmj.i90
  5. Starkstein, S.E., Jorge, R., Petracca, G., & Robinson, R.G. (2007). The construct of generalized anxiety disorder in Alzheimer disease. The American Journal of Geriatric Psychiatry, 15(1), 42-49. https://doi.org/10.1097/01.JGP.0000229664.11306.b9