DIMENSIONS Autumn 2001

ADRC Researchers Open Door to Understanding Anxiety in Alzheimer's Disease

by Cheryl Dawes

Memory problems and loss of cognitive function are, as yet, unchangeable aspects of Alzheimer's disease. However, other problems sometimes associated with AD can be changed. Research has shown that recognition and treatment of depression, which frequently goes hand-in-hand with AD, can alleviate a debilitating load that a patient need not carry. Anxiety, another unnecessary burden associated with AD, has received less attention than depression but is beginning to receive a great deal more.

Until recently, little was known about whether anxiety was widespread in AD and what role it might play in day-to-day and long-term care and quality of life of Alzheimer's patients. University of Washington ADRC researchers investigating these and other questions about anxiety in AD have begun to find answers.

The group of researchers led by Dr. Linda Teri, Professor of Psychosocial and Community Health, has conducted studies exploring the symptoms that constitute anxiety in people with AD, the way anxiety relates to other behavioral or cognitive problems and the effect these problems may have on the course of AD. Their results show that anxiety is common in AD, is often accompanied by depression, and the presence of anxiety symptoms is directly related to problem behaviors and can be predictive of nursing home placement.

In the studies funded by the National Institute on Aging and the National Institute of Mental Health, Teri and her colleagues, Drs. Rebecca Logsdon, Sue McCurry, Laura Gibbons and Louise Ferretti, looked at anxiety symptoms in various samples of patients with AD. The researchers' initial study examined the prevalence of anxiety in a group of 523 community-dwelling patients with AD who were members of a patient registry that was part of a larger study led by Dr. Eric Larson. The patients in the study had not necessarily sought help for their memory problems or other symptoms.

Teri and her colleagues collected information on cognitive and functional ability and behavioral symptoms for each patient. They found that 70 percent of the patients in this sample had one or more symptoms of anxiety, such as fearfulness, agitation or irritability. Their analysis also revealed that, in these patients, anxiety was related to behavior problems and a reduced ability to independently carry out activities of daily living, such as eating, dressing, and performing household tasks. In more than half of the patients, anxiety was accompanied by depression.

The researchers found a strong statistical relationship between reduction in daily activities and the presence of depression, and they found that problem behaviors could be attributed entirely to anxiety. Problem behaviors identified in the study included wandering, sexual misconduct, hallucinations, verbal threats, and physical abuse.

In a second study of 137 geriatric clinic patients diagnosed with AD who had come to the clinic seeking help with memory concerns, the researchers assessed a wider variety of anxiety symptoms. They used two independent standardized measures, dividing the patients into two groups. In one group, clinicians rated anxiety symptoms and their severity using a scale that is widely used for screening anxiety in older adults. In the other group, the patient's caregivers recorded the frequency of five anxiety symptoms.

As in the first study, the researchers found a high prevalence of anxiety and a strong association between anxiety and depression. In the group rated by clinicians, 66 percent of the patients had two or more symptoms of anxiety that were at least moderately severe. In the group rated by caregivers, anxiety symptoms such as appearing anxious, expressing fearfulness, and exhibiting restless or fidgety behaviors occurred in 40 to 68 percent of the patients (depending on the symptom) in the past week and up to 28 percent on a daily basis.

In a third study, looking at how anxiety in AD patients affects their long-term care, the researchers followed more than 400 AD patients for an average of four years. They found that patients who exhibited anxiety symptoms at their initial assessment for the study were much more likely to enter nursing homes than those who did not, regardless of the severity of their memory problems or other risks for institutionalization.

"These studies, put together, form the basis of an understanding about anxiety from a variety of different perspectives," notes Teri. "It gives us a much clearer picture than we had initially about how important this phenomenon is. Now we know it exists and we have a sense of what it looks like, but I think a lot more research is needed before we understand the array of anxiety symptoms that are possible and how they may adversely affect care."

One area where Teri sees a need for more research is to develop a better method for assessing anxiety in patients with AD. Currently there are no standard measures to specifically assess anxiety symptoms in people with dementia, she says. "I think anxiety research for AD now is where depression research was 10 to 15 years ago."

Teri and her colleagues already have a study underway that will explore how approaches to clinical care might be adapted to treat anxiety in AD. Teri's group had begun an intervention study of treating depression in AD, but the findings from their anxiety studies led them to make some changes to the study. "When we saw that anxiety is highly related to depression and in fact may be as important, if not more important than depression, we quickly revised our intervention," explains Teri. "Rather than just depression, our intervention now focuses on anxiety and depression." If treatment can alleviate anxiety and depression, the next question is: how does that affect quality of life and long-term care?

Although all the answers on anxiety and AD aren't in yet, Teri says that caregivers should keep in mind that anxiety can and should be addressed. "If you have a patient that seems to be anxious, see about getting some treatment. See what you can do to alleviate the anxiety, because anxiety may in fact make care that much more difficult."

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