The featured paper is ‘Anxiety in dementia: A critical review’ by Siegnourel and colleagues. The authors note in the introduction that the prevalence of anxiety disorders in people with dementia is between 5 and 21% before identifying three aims for this review:-
1. To define anxiety in dementia
2. To review the instruments that have been used to assess dementia
3. To critically review the clinical presentation of anxiety in dementia
The authors begin with a simple search strategy – combining dementia and anxiety and search two databases – PsycINFO and PubMed. By expanding the search to include sub-types of dementia it may have been possible to increase the initial number of articles returned (as not all subtypes will necessarily have been classified correctly under dementia and this would have depended on additional factors such as the year of publication as major index headings have changed over time). Additionally the search period was not specified. However the authors locate a large number of papers – 513 and then use a number of inclusion criteria to narrow down the papers to 74.
Defining Anxiety in Dementia
The authors first consider the question of how to define anxiety in dementia. There are some tricky issues here such as distinguishing anxiety from agitation, depression and the symptoms of dementia. There are a number of solutions covered in this section including Starkstein’s empirical approach in which excessive anxiety or worry together with 3 out of 5 of respiratory symptoms, irritability, muscular tension, restlessness and fears for a diagnosis. In looking at the differences between anxiety and the other constructs the authors have also examined studies looking at the correlation between these constructs and concluding that there was evidence to distinguish anxiety and agitation, equivocal evidence for a distinction between anxiety and depression
The authors then examine four scales which can assess anxiety in dementia – the Neuropsychiatric Inventory, the BEHAVE-AD, the Worry Scale and the RAID. The authors note that each of the scales has its own set of difficulties and such difficulties might include validity (e.g. distinguishing depression from anxiety), reliance on the caregiver for diagnostic clarification, limitations on sources of information or lack of empirical data in identifying scale items. The authors comment particularly on the RAID’s use of multiple sources of information.
The authors identified demographic features of the subjects with dementia and anxiety noting higher scores on anxiety with increasing age, no relationship between anxiety and education in Alzheimer’s Disease. The authors also examine ethnicity and find evidence supporting higher levels of anxiety in Asians and Hispanic people with dementia than in African-American or Caucasian people with dementia. With regards to subtypes of dementia there was some supporting evidence for greater anxiety levels in the Vascular and Frontotemporal dementias than in Alzheimer’s Disease. The authors also suggested higher levels of insight were associated with higher anxiety levels and that anxiety lowers at the profound stages of dementia although the story is more complex than this with the authors considering some of the more subtle nuances. The authors then consider how research in this area could be developed with an examination of further themes.
This review offers a useful overview of the difficulties surrounding the diagnosis of anxiety in dementia and highlights how much work remains to be done.
Seignourel P.J, Kunik M.E, Snow L, Wilson N and Stanley M. Anxiety in dementia: A critical review. Clinical Psychology Review. 28. 2008. 1071-1082.
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