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Anxiety in individuals with and without cognitive impairments Ladislav Volicer, MD, PhD School of Aging Studies, University of South Florida, Tampa, FL and 3rd Medical Faculty, Charles University, Prague, Czech Republic ANXIETY • An unpleasant state of inner turmoil, often accompanied by nervous behavior, such as pacing back and forth, somatic complaints and rumination • Feeling unrealistic fear, worry, and uneasiness, usually generalized and unfocused • Often accompanied by restlessness, fatigue, problems in concentration, and muscular tension Types of Anxiety • Generalized Anxiety Disorder ‐ excessive, uncontrollable and often irrational worry about everyday things that is disproportionate to the actual source of worry • Social Phobias • Test and performance anxiety PHOBIAS Ablutophobia – fear of bathing, washing, or cleaning Achluophobia – fear of darkness Acrophobia – fear of heights Agoraphobia– fear of places or events where escape is impossible or when help is unavailable. Agrizoophobia – fear of wild animals Agyrophobia – fear of crossing the road Aichmophobia – fear of sharp or pointed objects Ailurophobia – fear of cats Algophobia – fear of pain Amychophobia – fear of being scratched Anthophobia – fear of flowers Anthropophobia – fear of people TREATMENT OF PRIMARY ANXIETY • Psychotherapy: Cognitive Behavioral Therapy (CBT), Hypnotherapy • Pharmacological: – Beta blockers – somatic symptoms – Anxiolytics – benzodiazepines, hydroxyzine, pregabalin CONDITIONS THAT MAY CAUSE ANXIETY • Medical conditions: chronic obstructive pulmonary disease (COPD), heart failure, or heart arrythmia • Other psychiatric conditions: depression, schizophrenia, obsessive‐compulsive disorder, Posttraumatic Stress Disorder, Substance Induced Anxiety Disorder • Dementia • Caregiving • End of life Features of Schizophrenia Positive symptoms Delusions Hallucinations Functional Impairments Work/school Interpersonal relationships Self-care Cognitive deficits Attention Memory Verbal fluency Executive function (eg, abstraction) Disorganization Speech Behavior Negative symptoms Anhedonia Affective flattening Avolition Social withdrawal (most predictive of poor outcome) Alogia Mood symptoms Depression/Anxiety Aggression/Hostility Suicidality 7 Assessing the Degree of Suicidal Risk [Behavior or Symptom] [Intensity of Risk] Low Moderate High Anxiety Mild Moderate High, or panic state Depression Mild Moderate Severe Isolation-withdrawal Some feelings of helplessness, hopelessness, and withdrawal Fairly good in most Moderately good in activities some activities Hopeless, helpless withdrawn & selfdeprecating Several Few or none Daily functioning Resources Vague feelings of depression, no withdrawal Some Not good in any activities (Hatton D, Valente S. Rink A: Suicide Assessment and Intervention, p.56. New York, Appleton-Century-Crofts. 1977) PROCEDURE: 1.Review the resident’s level of suicidal risk using the table “Assessing the Degree of Suicidal Risk.” •If the risk is moderate or high, contact the family and physician. •If social services is interacting with the health care professionals, include this information in the plan of care and reference in the progress notes. 8 DEPRESSION AND ANXIETY Anxiety Disorder Pure Comorbid Comorbid Disorder Depression Anxiety --------------------------------------------------------------------Gener.anx.dis. 70% 30% Phobia 75% 25% Panic 50% 50% Obses.comp.dis. 56% 44% Major depression 53% 47% --------------------------------------------------------------------Beekman et al, Am.J.Psychiatry 157:89-95, 2000 ANXIETY IN DEPRESSION • Treat depression not anxiety • Anxiolytics – Do not resolve depression – Do not reduce suicide risk – Increase risk of falls and hip fracture – Decrease CNS functioning (Granek et al, J.Am.Geriat.Soc. 35:503-511, 1987) Relationship between the MDS diagnosis of depression and the treatment with antipsychotics and antianxiety medications MDS diagnosis Total Chi2 p No depression Mild depression Severe depression Antipsychotics (24.6% dg psychosis) 18.3% (191/850) 32.9% (149/304) 44.0% (155/197) 26.8% 99.74 <.001 (495/1351) Antianxiety (17% dg anxiety) 10.6% (110/931) 15.5% (70/383) 24.4% (86/266) 14.4% 41.53 <.001 (266/1580) Percentages refer to proportion of treated residents in the cell. Numbers refer to the ratio of treated over untreated residents. LOW DETECTION • Depression (1997-1998 surveys) – Older patients (56% less likely) – African-Americans (37% less likely) – Medicaid (35% less likely) • Family physicians 65% more likely to record a diagnosis than internists • Anxiety detection rate 10% Harman et al, J.Gen.Intern.Med. 17:165-172, 2002 CONSEQUENCES OF COMORBID ANXIETY • • • • Greater severity of depression Greater likelihood of suicidal ideation Lower social function Greater severity of somatic symptoms Lenze et al, Am.J.Psychiatry 157:722-728, 2000 COMBINATION OF DEPRESSION AND ANXIETY INCREASES • Dysfunction, suffering, diminished quality of life • Physical symptoms • Disability • Utilization of healthcare resources • Medical mortality and suicide After Mulsant BH PSYCHOTHERAPY FOR DEPRESSION • Psychodynamic Therapy • Interpersonal Therapy • Cognitive Behavioral Therapy – Rational emotive behavior therapy – Dialectical behavior therapy MUSIC THERAPY • Weekly music and activity program decreased behavioral and depressive symptoms (Han et al, Dement Geriatr Cogn Disord 30, 540, 2010) • Biweekly music therapy improved symptoms of depression (Raglio et al, Curr Aging Sci 3, 242, 2010) • Weekly individual music therapy sessions decreased anxiety and depression (Guetin et al, Dement Geriatr Cogn Disord 28, 36, 2009) • RTC trial of music therapy found decreased number of depressive symptoms and improved self‐esteem (Cooke et al, J Health Psychol 15, 765, 2010) ANTIDEPRESSANT SELECTION • Tricyclic antidepressant obsolete because of side effects (anticholinergic, cardiovascular) except when cost is a concern • Selective serotonin reuptake inhibitors are first choice – Citalopram (Celexa) – Sertraline (Zoloft) • Venlafaxine (Effexor) first alternative RESIDUAL SYMPTOMS IN DEPRESSION • Residual insomnia – Trazodone – Zolpidem (Ambien) – Zaleplon (Sonata) • Residual anxiety – Increase the dosage of the antidepressant 2001 Geriatric Depression Guidelines DEMENTIA Memory Social withdrawal DEPRESSION impairment Impaired concentration Depressed mood Aphasia Sleep disruption Irritable mood Apraxia Loss of interest Loss of energy Agnosia Feeling of Executive hopelessness impairment Excessive worry Feeling of Agitation helplessness Suicidal thoughts Impaired appetite Physiological arousal Phobias Panic attacks ANXIETY DISORDER ANXIETY IN MCI • 161 patients, anxiety in 52% • Associated with earlier conversion to AD (Gallagher et al, Int J Geriatr Psychiatry. 2011 Feb;26(2):166‐72) LOW HIGH Wilson et al, Am J Geriatr Psychiatry. 2011 Apr;19(4):327 ANXIETY IN DEMENTIA • At first dg (mild dementia) – 19.5% had clinically significant anxiety – 22.5% had subclinical anxiety. Half of the patients reported experiencing anxiety from time to time. – More in Lewy‐body dementia than in Alzheimer's disease (Hynninen et al, Int Psychogeriatr. 2012, 24(11):1771) • Related to agitation (not symptoms of autonomic sensitivity) (Twelftree et al, Aging Ment Health. 2006 Jul;10(4):362) ANXIETY IN ASSISTED LIVING • Similar prevalence in residents with and without dementia: 45% at least mild anxiety by examination, 22% by proxy (Smith et al, Res Gerontol Nurs. 2008 Apr;1(2):97) • Anxiety in 11 ‐18% of residents with dementia, related to staff skill (Neville & Teri, Int J Ment Health Nurs 2011 20(3):195) NON‐PHARMACOLOGICAL TREATMENT • Music therapy – percussion instruments with familiar music, 30 min/day, 2/week, for 6 weeks (Sung et al, Int J Geriatr Psychiatry 2012;27(6):621‐7) • Preferred music listening – 30 min/day, 2/week, for 6 weeks (Sung et al, J Clin Nurs. 2010 Apr;19(7‐8):1056) • RTC – weekly receptive music therapy (Guetin et al, Dement Geriatr Cogn Disord 2009;28:36) ACTIVITY PROGRAMS I N D E P E N D E N C E MILD MODERATE MEMORY ENHANCEMENT PROGRAM SEVERE TERMINAL NAMASTE CARE THE CLUB TIME NAMASTE CARE • Presence of others – group room, carer always present (7 days/week, 5hrs/day) • Comfortable environment – reclining chairs, bird sounds, relaxing music, lavender scent • Individualized care – hand and foot massage, ADL as meaningful activities • Easy to implement, no additional staffing J. Simard: The End-of-Life Namaste Care Program for People with Dementia, Health Professions Press 2007 Psychoactive Medications before and after Namaste Enrollment Medication Antipsychotics Days administered 2.57 2.72 Number of residents 32 34 Antianxiety 0.80 0.49* 11 6 Antidepressants 4.37 4.14 54 52 Hypnotics 0.05 0.01 1 1 * p = .035 NEUROPSYCHIATRIC INVENTORY (NPI) • • • • • • Delusions Apathy Hallucinations Disinhibition Agitation/aggression Depression • Aberrant motor behavior • Anxiety • Night-time behavior • Euphoria • Appetite and eating changes Cummings et al, Neurology 44:2308-2314, 1994 Effect of Galantamine on Behavioral Symptoms in AD Dose increments Mean (± SE) change from baseline in NPI –3 –2 Improvement –1 * 0 1 2 † 3 Placebo Galantamine 16 mg/d Galantamine 24 mg/d 4 5 6 0 3 1 Months * p < 0.05 vs placebo (galantamine 16 and 24 mg). † p < 0.05 vs baseline. 5 Deterioration Reprinted with permission from Tariot PN et al. Neurology. 2000;54:22692276. Effect of galantamine on Behavioral Symptoms in AD NPI Individual Items Aberrant Motor Behavior Agitation/Aggression Anxiety Apathy Delusions Depression/Dysphoria Disinhibition Elation/Euphoria Hallucinations Irritability NPI Distress Total NPI Highlighted = Clinical significance (p < 0.05) over 5 months for GALANTAMINE 24 mg/day vs placebo. Tariot PN et al. Neurology. 2000;54:2269-2276. Galantamine effect in vascular dementia Mean (± SE) change in NPI score from baseline –3 Improvement –2 * –1 0 1 2 3 4 REMINYL 12 mg bid (n = 106) Placebo (n = 106) 5 6 Baseline M1 M3 M5 Deterioration * p < 0.05 vs placebo. Baseline Neuropsychiatric Inventory (NPI) score: 15 (REMINYL 12 mg Wilkinson DG et al. IJCP. 2002;56:509-514. bid)/13 (placebo). Change in NPI Items in vascular dementia Aberrant motor behavior Agitation/aggression Anxiety* Apathy/indifference* Delusions* Depression/dysphoria Disinhibition Elation/euphoria Hallucinations Irritability/lability * p < 0.05 vs. placebo. Adapted from Erkinjuntti T et al. Lancet. 2002;359(9314):1283-1290. Data on file, Janssen Pharmaceutica Products, L.P. * *p<0.05 vs baseline; ***p<0.001 vs baseline * -3 * -2.5 * -2 * *** Improvement -3.5 * * -1.5 -1 -0.5 Appetite/eating Nighttime beh. Euphoria Disinhibition Delusions Depression Hallucinations Study B452; Observed case analysis Apathy Aberr. motor behavior Anxiety Irritability 0 Agitation Mean Change from Baseline BEHAVIORAL EFFECTS OF RIVASTIGMINE Cummings JL, et al. Behavioral benefits in Alzheimer's disease patients residing in a nursing home following 52 weeks of treatment with rivastigmine. Presented at the APA 2000 Annual Meeting, May 13-18, 2000, Chicago Memantine in Moderate to Severe AD Mean Change From Baseline in NPI Score ‐0.6 ‐0.4 Memantine Placebo *P=.0386 ‐0.2 *P=.0083 Improvement Worsening 0.0 0.2 0.4 0.6 0.8 1.0 Delusions Hallucinations Agitation/ Depression/ Aggression Dysphoria *LOCF analysis at Week 28 Source: Data on file. Forest Laboratories, Inc. Anxiety Elation/ Euphoria PSYCHIATRIC CONSEQUENCES OF CAREGIVING • ANXIETY - in 21 - 76 % of caregivers, related to hours of care, physical and psychological illness scores, low education, lack of time for leisure activities (Vellone et al, 2002, Sansoni et all, 2004) • CBT improved anxiety and coping strategies in caregivers, and neuropsychiatric symptoms and quality of life in care recipients (Fialho et al, Arq Neuropsiquiatr.. 2012, 70(10):786‐92) CAREGIVING BURDEN PRIMARY STRESSORS Care recipient disability Psychiatric symptoms Care decisions SECONDARY STRESSORS Family conflict Work difficulties Appraisal of demands and adaptive capacity Perceived stress Emotional/behavioral response MORBIDITY/MORTALITY Adapted from Schulz and Martire, Am J Geriatr Psychiatry 12:204, 2004 PSYCHIATRIC PROBLEMS AT THE END OF LIFE • • • • • Depression Anxiety Insomnia Delirium Fatigue ANXIETY • May be a normal response to the situation – fears, uncertainty, reaction to physical condition, social or spiritual needs • Usually with 1 or more of the following signs – agitation, restless, sweating, tachycardia, hyperventilation, insomnia, excessive worry, tension • About 5% are affected by agoraphobia ANXIETY AT END OF LIFE • Much anxiety near the end of life may stem from not talking. • People think that the dying person doesn't know she's dying and don't want to tell her, and the dying person absolutely knows that she's dying but doesn't want to burden her loved ones. So nobody's on the same page. (Marsha Gallagher, LCSW, a social worker with Capital Caring) NEED FOR PALLIATIVE CARE IN DEMENTIA • Symptoms during last 3 months – Physical: pain 86%, problems with personal cleanliness 81%, dyspnea 75%, incontinence 59%, fatigue 52% – Emotional: depressed mood 44%, anxiety 31%, loneliness 21% • More treatment needed for emotional symptoms, personal cleanliness, pain • Good death reported in 58% Reynolds et al, J Palliat Med 5;895,2002 CANCER‐RELATED FATIGUE • • • • • • • • • • Direct effect from cancer and/or treatments Sedating medications Deconditioning Depression/anxiety Hypoxemia or anemia Systemic infection of organ insufficiency Electrolyte abnormalities Nutritional imbalance/impairment Sleep disturbance Uncontrolled pain Copyright © 2010 Center for Hospice, Palliative Care , & End‐Of‐Life Studies 41 ANXIETY DISORDER IN ADVANCED CANCER • Diagnosed in 7.6% of patients • More likely in women, younger patients, with worse physical performance status • Had less trust in their physicians, felt less comfortable asking questions about their health, and felt less likely to understand the clinical information that their physicians presented • Were more likely to believe that their physicians would offer them futile therapies and would not adequately control their symptoms. Spencer et al, Cancer. 2010 Apr 1;116(7):1810‐9 SYMPTOMS BEFORE DEATH IN PALLIATIVE CANCER PATIENTS Symptom One-month mean One-week mean (SD) (SD) Appetite 46.8 (29.9) 60.3 (32.1) Tiredness 43.2 (20.0) 58.5 (25.0) Depression 32.9 (22.7) 38.5 (29.1) Well-being 42.4 (23.5) 49.0 (23.4) Pain 37.5 (22.7) 44.0 (26.9) Anxiety 33.4 (24.0) 38.1 (28.5) Nausea 18.4 (16.0) 25.7 (24.9) Shortness of Breath 24.0 (21.1) 31.7 (27.2) Drowsiness 39.8 (22.5) 55.6 (27.7) Symptoms scored 0 = best possible to 100 = worst possible Olson et al, BMC Medical Research Methodology, 8, 36, 2008 Copyright © 2010 Center for Hospice, Palliative Care , & End‐Of‐Life Studies 43 DEATH ANXIETY IN CAREGIVERS • Younger nurses have more anxiety and have negative attitude towards end‐of‐life patient care • Worksite death education program is needed to reduce death anxiety (Peters et al, Open Nurs J. 2013;7:14‐21)