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NT DBMAS - Presentation: Anxiety in Dementia

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  • 1. Anxiety in Dementia Prof Philip Morris MB BS BSc(med) PhD FRANZCP FAChAM (RACP) AmBPN Consultant Psychogeriatrician NT Dementia Behaviour Management Advisory Service Frontier Services
  • 2. Overview
    • 1. The concept of dementia
    • 2. Anxiety symptoms and disorders
    • 3. Distinguish from dementia
    • 4. Distinguish from depression
    • 5. Distinguish form agitation
    • 6. Sources of information
    • 7. Criteria for anxiety disorders in dementia
    • 8. Anxiety measurement
    • 9. Clinical correlates of anxiety in dementia
    • 10. Causes of anxiety in dementia
    • 11. Clinical assessment of anxiety and agitation
    • 12. Treatment of anxiety in dementia
    • 13. Approach to treatment of agitation
    • 14. Summary
  • 3. Dementia DSM-IV definition Degenerative brain disease Progressive cognitive impairment Affects memory and either aphasia, apraxia, agnosia, or executive functions Causes disability Main types Alzheimer’s disease Vascular cognitive impairment Mixed disease Dementia with Lewy bodies Parkinson’s disease dementia Frontotemporal dementia ((progressive aphasia, semantic dementia, behavioural variant) Normal pressure hydrocephalus Alcohol induced dementia or amnestic disorder Huntington's disease Creutzfeldt-Jakob disease AIDS-related dementia
  • 4. Anxiety Common problem in dementia: 5-21% prevalence Symptoms Cognitive Physical Disorders Adjustment disorder with anxiety Panic disorder +/- agoraphobia General anxiety disorder Phobia Social anxiety Obsessive compulsive disorder Acute stress disorder Post traumatic stress disorder Anxiety disorder NOS
  • 5. Distinguish from dementia Overlapping symptoms Concentration, fatigue, restlessness Focus on patient experience “ Excessive worry difficult to control” Caregivers may miss symptoms Distinguish from depression Anxiety and depression may not be distinct clinical entities Agitation common in depression and may be a symptom of anxiety Depressive disorders highly co-morbid with anxiety conditions in dementia (60-80%) Distinguish from agitation Severe anxiety associated with motor restlessness Cognitive experience different Global disturbance of behaviour (episodic or continuous)
  • 6. Use multiple sources of information Need to modify symptom criteria for anxiety disorder in dementia Anxiety measurement General neuropsychiatric measures – anxiety scales NPI BEHAVE-AD Specific dementia anxiety measures The Worry Scale The RAID
  • 7. Clinical correlates of anxiety in dementia Sex Age Type of dementia Severity Insight Language Lower quality of life Night time behaviour disturbance Caregiver burden Earlier placement
  • 8. Causes of anxiety in dementia Damage to brain structures responsible for anxiety control Depletion of neurotransmitters relevant to anxiety Genetic vulnerability Previous anxiety experience, trauma, abuse Separation anxiety Losses from social field Fear - Further impairment Maltreatment Abandonment Medication side effects Medication or drug withdrawal Medical conditions
  • 9. Assessment of anxiety (and agitation) “ ABCs” Antecedents Behaviours Concurrent/co-morbid stresses Consequences Medical workup Physical examination Laboratory tests Urine analysis Cognitive screen
  • 10. Treatment of anxiety in dementia 2009 - No systematic studies! Guiding principles Use methods for designed for other treatment situations Psychotherapy needs modification depending on cognitive state of patient Avoid use of benzodiazepines long term (OK for acute sedation) Psychotropic medications Antidepressant anxiolytics SSRIs SNRIs Mirtazapine Non-benzodiazepine anxiolytic – buspirone Beta-blockers Mood stabilizers Atypical (second generation) antipsychotics Risperidone Olanzapine Quetiapine Possible role of cholinesterase inhibitors
  • 11. Approach to general treatment of agitation “ TREAT” Target symptoms Reversible causes Environment Agents – medications Try again Approach to psychotropic treatment of agitation Target symptoms Treat co-morbid psychiatric conditions Use medication that was useful in past Watch for adverse interactions with other medications Avoid side effects
  • 12. Summary Anxiety symptoms and anxiety disorder are a common problem in dementia Anxiety in dementia is a neglected area of study and practice No systematic studies of psychosocial or medication treatments available for guidance Methods of treating anxiety in other settings need to be modified for application in dementia Thank You