Clinical psychology and anxiety and depression in dementia three case studies
Latest News. By Rheumatology Advisor Contributing Writer. Investigators addressed the association between long-term use of hydroxychloroquine therapy and the risk for Alzheimer disease. Stepwise screening starts with a single question on subjective memory loss. By Steve Duffy.
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A phase 3 trial evaluating pimavanserin Acadia for the treatment of dementia-related psychosis has been stopped early due to positive findings in a planned interim efficacy analysis. Use of hearing aids is associated with lower risks for being diagnosed with Alzheimer disease, dementia, depression, anxiety, and injurious falls among elderly adults diagnosed with hearing loss. By Emily Pond.
Patients with Alzheimer disease who participated in elastic resistance exercises showed changes in depressive symptoms, muscle function, and muscle mass. By Caleb Rans. That is, older anxious adults may experience other symptoms that are not being assessed or may experience the same symptoms but use different terminology to describe them. For example, Flint 75 discussed that anxiety among older adults may be described and experienced as more somatic in nature with complaints, such as dizziness and shakiness, than in younger age groups.
However, direct empirical evidence is lacking. If the expression of symptoms does differ in older adults, diagnosticians may miss anxiety disorder cases among the elderly; only older patients whose anxiety symptoms present similar to younger adults will be diagnosed with an anxiety disorder. This problem is inevitable, but should be considered when evaluating currently identified similarities and differences between younger and older individuals.
Clearly, there is a need for more research on these questions. Geriatricians should be queried about the types of symptoms they see in older patients who they believe may be suffering from anxiety problems. The Life Span Study group recommended that consideration be given to the interactions between advancing age and comorbid medical and psychiatric illness. It is well established that anxiety and depression frequently are comorbid in younger adults.
More specifically, Beekman et al. The authors also reported that comorbid anxiety disorders were associated with lower social functioning. In contrast, there was no significant association between comorbid anxiety disorders and physical functioning.
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Porensky et al. In younger adult samples, longitudinal and epidemiological studies suggest that anxiety disorders precede mood disorders, 78 , 87 with the possible exception of GAD and OCD. Most cases of GAD tended to be present as a single, chronic episode with a mean duration of Discrepancies in the literature may be a result of limitations similar to those discussed in the prevalence section. Differences in methodology, such as stringency of assessment, sampling procedure, and age groups evaluated, are likely to significantly limit our ability to draw firm conclusions about the chronology of comorbid GAD and MDD, particularly among older adults whose recall for dates of onset may be unreliable.
Consistent with these high comorbidity rates, data from the same study indicated that Interestingly, several review articles have argued that the typical presentation of anxiety in older adults seen in clinical practice is mixed anxiety—depression. Furthermore, research has revealed a low prevalence for mixed anxiety—depression in the general adult population 98 as well as in primary care samples, 99 and demonstrated instability of the classification.
Currently, these problems may be best described as NOS diagnoses. Taken together, the findings regarding comorbidity suggest that: a as with younger adults, anxiety disorders among the elderly often occur alongside other disorders, particularly MDD and substance use disorders; and b findings are equivocal with regard to the chronology of comorbid anxiety and mood disorders, with little information about the course of these disorders in older adult samples. The impact of comorbid disorders among older adults with anxiety disorders indicates a variety of negative consequences.
More specifically, the presence of depression has been associated with higher severity of GAD among older adults; likewise, the presence of GAD symptoms among depressed older adults has been associated with greater suicidality. Finally, comorbidity may impede treatment responsiveness. One study, investigating a large clinical population of depressed older adults aged 60 and older , found that while those with MDD and comorbid PD responded as well to psychiatric treatment in primary care settings as those with no comorbid anxiety disorders, those with MDD and comorbid PTSD showed a delayed response to treatment.
Certain medical conditions have demonstrated an association with anxiety disorders and anxiety symptoms, such as gastrointestinal problems, hyperthyroidism, and diabetes. Furthermore, the link between anxiety and medical illness, particularly cardiovascular disease, is associated with increased mortality. For example, anxiety has been found to pose an increased risk for mortality after heart surgery, and panic attacks have been found to be associated with increased risk for cardiovascular morbidity and mortality.
A growing body of research has focused on cardiac problems, respiratory conditions, and vestibular problems. Symptoms of these medical conditions are particularly relevant to anxiety disorders given their reciprocal nature. Also, patients with bona fide medical conditions may develop anxiety about their symptoms. Chest pain and cardiac symptoms are commonly comorbid with anxiety disorders in older age samples. Todaro et al. The mean age of the sample was Other research has found the presence of anxiety symptoms to be a risk factor for the development of future coronary heart disease.
The high overlap between anxiety and true cardiovascular disease, as well as misattributed cardiovascular symptoms, renders attribution of symptoms to cardiac versus anxiety disorders problematic. Many patients with anxiety may be overlooked if their physicians attribute their symptoms solely to heart disease. Respiratory disorders also are highly comorbid with anxiety disorders.
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Perhaps, not surprisingly, older adult patients with COPD who present with comborbid anxiety or depression show more functional impairment than those COPD patients without comorbid anxiety or depression. Other respiratory problems have been examined as well. One study found that asthma was associated with anxiety disorders sample aged 60 and older , but that this association did not attain statistical significance.
Vestibular symptoms represent another medical comorbidity. For example, Downton and Andrews found that in adults over the age of 75 with postural disturbance, dizziness and falling were associated with higher levels of anxiety and this association was even stronger in individuals who had experienced a fall within the last 12 months. Gagnon et al. Elsewhere, among 56 older adults seeking medical help for a postural disturbance, For example, one study found that PD was associated with an earlier age of onset of Parkinson's, higher rates of motor fluctuations, and morning dystonia.
In contrast, Stein et al. These discrepancies suggest that more research is needed in this area.
The comorbidity between medical illness and anxiety disorders poses difficulties for differential diagnosis and detection of anxiety. Researchers have suggested that older adults may be more likely to attribute physical symptoms related to anxiety to medical issues, including muscle tension, hypervigilance, and difficulties related to sleep. Furthermore, the symptoms that result from medical illnesses may produce fearful bodily sensations that may result in the subsequent development of anxiety disorders.
Longitudinal research investigating a number of medical conditions independently is needed to evaluate a whether specific medical conditions predict the onset of anxiety disorders and b whether the presence of anxiety disorders and which ones predict the onset of certain medical conditions. Anxiety disorders are frequently comorbid, with cognitive decline and dementia among the elderly. Cognitive decline is an important consideration when defining anxiety disorders in this age group because it may affect presentation of symptoms, experience of symptoms, as well as the ability to communicate them.
Longitudinal research has demonstrated that anxiety in late life may increase the risk of cognitive decline over and above the risk associated with increasing age. A longitudinal study of older adults 60 and older , assessed at baseline and again on average 3. Interestingly, depression did not predict cognitive impairment.
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The authors refuted earlier findings that the association between anxiety and cognitive decline is due to greater use of benzodiazepines. As with medical conditions, the association between anxiety and cognitive decline may be bidirectional: chronic anxiety may cause cognitive impairment and anxiety may also develop after cognitive impairment, perhaps although speculative in response to the awareness that cognitive abilities are declining. The wide range of prevalence estimates may result from the limitations of heterogeneous methodology across studies and difficulty discerning valid diagnoses of anxiety in the context of dementia.
The distinction between these disorders is difficult for several reasons. One of the primary difficulties is differentiating between the symptoms of each disorder, as there is a fair amount of overlap between them i. In addition, symptoms of anxiety may arise in response to valid concerns when experiencing functional decline and cognitive changes due to dementia, or as a direct result of neurological degeneration caused by dementia that affects areas of the brain responsible for the emotional and physiological disturbances seen in anxiety disorders.
Some argue that the anxiety that is secondary to dementia is presented as agitation or hoarding behavior. Several studies suggest that anxiety may be a risk factor for dementia. Palmer et al. Among individuals with both MCI and anxiety, the relative risk of developing AD almost doubled with each anxiety symptom, from 1. Gallacher et al. The authors posited that anxiety may be a risk factor for cognitive impairment and dementia, and while the reverse relationship cannot be ruled out, it is less likely as participants with evidence of cognitive decline at baseline were excluded.
Given the difficulty that patients with dementia may have with relaying information about themselves, many researchers have chosen to rely on caregiver report. Caregivers may be better able to observe and properly report behavioral manifestations of anxiety than the patients themselves; however, it is unlikely that they are well suited to report internal symptoms, such as worry, rumination, and concentration difficulties.
In sum, there appears to be comorbidity between anxiety and cognitive decline and dementia in the elderly. Issues of assessment and differential diagnosis warrant further investigation. Wetherell et al. Similarly, Porensky et al.