INTERNATIONAL J O U R N A L OF GERIATRIC PSYCHIATRY, VOL.

11: 987-990 (1996)

ANXIETY DISORDERS IN DEMENTIA

SUFFERERS
CLIVE BALLARD
Clinical Scientist, M R C Neurochemical Pathology Unit, Newcastle General Hospital, Newcastle upon Tyne, U K
ANN BOYLE
Senior Registrar in Psychiatry ,for the Elderly, Leicester General Hospital, Leicester, UK
CLAIRE BOWLER* A N D JAMES LlNDESAYt
*Lecturer in Psychiatry f o r the Elderly, ?Professor of Psychiatry for the Elderly, University of Leicester, Leicester. UK

SUMMARY
One hundred and fifty-eightconsecutivepatients attending a university memory clinic were assessed using a variety of
standardized instruments. Dementia was diagnosed according to DSM-III-R criteria. One hundred and nine patients
had DSM-111-R dementia, of whom 22% had subjective anxiety, 11 YO experienced autonomic anxiety, 38%
experienced tension, 13% experienced situational anxiety and 1.8% had panic attacks. Thirty-two (29.4%) had one
or more anxiety symptoms. None of the cognitive or demographic variables were significantly associated with the
presence of anxiety symptoms. Three main categories of anxiety symptoms were evident-anxiety related to
depression, anxiety related to psychosis and anxiety related to interpersonal situations.

KEY WORDS-dementia; anxiety; memory clinic

There has been an increased focus upon psychiatric
symptoms occurring in the context of dementia
over the last decade. Although studies have begun
to elucidate many of the important facets of
depression and psychotic symptoms in dementia
sufferers (Burns, 1991; Ballard and Oyebode,
1995), little study of anxiety symptoms has been
undertaken. Wands et al. (1990) used the Hospital
Anxiety and Depression Scale to investigate
anxiety among 50 patients with mild dementia,
38% of whom had possible or probable anxiety
disorder. Ballard et a/. (1994) found 31% of
dementia patients in contact with a day hospital
to fulfil the research diagnostic criteria for general-
ized anxiety disorder although half of these
patients experienced anxiety in the context of
RDC major depression. In the latter study, anxiety
disorders were more common in patients with mild
dementia and patients who retained insight into
their condition, although neither was a significant
Address for correspondences: Dr C. Ballard, MRC Neuro-
chemical Pathology Unit, Newcastle General Hospital, West-
gate Road, Newcastle upon Tyne NE4 6BE, UK. Tel: (0191)
2735251. Fax: (0191) 2725291.
CCC 0885-6230/96/110987-04
0 1996 by John Wiley & Sons, Ltd.
association. There is also a literature describing
anxiety problems among stroke patients (Burvill
et a/., 1995; Starkstein and Robinson, 1989),
adding weight to the suggestion that anxiety symp-
toms occur frequently in patients with organic
brain damage.
No diagnostic criteria have been developed for
anxiety disorders in dementia sufferers. This
presents considerable difficulties as many items
included within rating scales and diagnostic criteria
designed for other patient groups, such as sleep
disturbance and poor concentration, may have a
multifactorial origin in dementia sufferers. There
are also potential areas of overlap between anxiety
and agitation. Agitation is itself a vague concept
covering a range of symptoms. The overlap can be
minimized by focusing upon subjective, muscular
and autonomic symptoms of anxiety but omitting
motor symptoms such as restlessness from con-
sideration. Criteria need to be prospectively devel-
oped, based upon symptoms which cause distress
or interfere with functioning and that are likely to
persist over a period of months. As the current
study is cross-sectional, these goals cannot be
achieved and symptoms of anxiety are reported.
Received 22 August 1995
Accepted 23 November 1995
988 C. BALLARD, A. BOYLE, C. BOWLER AND J. LINDESAY
METHODS
Referrals to the University Memory Clinic in
Leicester were assessed using a standardized
package. The clinic is multidisciplinary and pro-
vides a detailed assessment service for patients with
cognitive impairment referred by general practi-
tioners and other doctors. Approximately two-
thirds of referrals suffer from dementia. Consecu-
tive completed assessments from the inception of
the clinic in 1991 until November 1994 are
reported. Assessments were conducted in a multi-
disciplinary manner. Each patient and informant
was seen by a psychiatrist, a geriatrician, a speech
therapist and a psychologist. Specific structured
questionnaires were completed, which gave back-
ground information about the history and symp-
toms of any cognitive impairment, activities of
daily living, any concurrent psychiatric morbidity
and a full physical examination. Demographic
data were also recorded in a standardized way.
These included information concerning the
patient’s age, gender and insight into the dementia
as well as details of further education and marital
status.
Anxiety symptoms were rated as part of the
standardized questionnaire. These included the
questions, ‘Do you feel more tense and worry more
than usual?’, ‘Have you felt more irritable lately?’,
‘Have there been times lately when you felt very
anxious or frightened?’, ‘Have there been times
lately when you felt anxious and physically unwell
(eg shaky, sweaty, heart pounding)?’, ‘are there any
special situations which make you anxious?’, ‘Have
you had attacks of fear or panic when you thought
you would collapse or lose control of yourself?’.
The duration of anxiety symptoms was ascertained.
Sleep items were also rated, but these were not
included as part of the anxiety profile in view of the
multiple causes of sleep disturbance among
dementia suffers. Depression was assessed from a
number of standardized questions, from which a
clinical diagnosis was made.
Dementia was diagnosed according to DSM-
111-R criteria (American Psychiatric Associ-
ation, 1987). The NINCDS-ADRDA criteria
(McKhann et al., 1984) for Alzheimer’s disease,
the Hachinski scale (Hachinski et al., 1975) for
vascular dementia and the McKeith et al. (1992)
criteria for senile dementia of Lewy body type were
used to make specific diagnoses. Cognitive assess-
ments were undertaken with a package which
included the CAMCOG schedule (Roth et al.,
1986). A full blood screen and CT scan were
undertaken to aid diagnosis.
Statistical evaluations were undertaken using the
SPSS computer package (SPSS, 1988). A principal
components analysis was undertaken to try to
identify a meaningful cluster or cluster of anxiety
symptoms. Symptoms with a correlation of +0.6
or greater with a factor were considered to be
associated with that factor. The severity of cogni-
tive impairment (as measured by the CAMCOG
score) was compared between patients with and
without anxiety symptoms using the Mann-
Whitney U test. The same test was used to compare
age between the two groups. The number of
patients who retained insight into their dementia,
the gender balance and the number of patients with
Alzheimer’s disease or vascular dementia respec-
tively were compared between those with and
without anxiety symptoms using odds ratios (OR)
with 95% confidence intervals (CI).
RESULTS
One hundred and fifty-eight assessments were
completed over the study period. One hundred
and nine of the patients fulfilled the DSM-111-R
(American Psychiatric Association, 1987) criteria
for dementia. Seventy-one (65.1 YO)patients were
female and 38 (34.9%) were male. Their mean age
was 73.5 years and they scored an average of 58.7
on the total CAMCOG schedule, with scores
ranging from 11 to 88. Twenty-four (22.0%)
patients had subjective anxiety, 12 (1 1 .O%) experi-
enced autonomic anxiety , 42 (38.5%) experienced
tension symptoms, 14 (12.8%) experienced situa-
tional anxiety and two (1.8%) experienced panic
attacks.
Considering the principal components analysis,
the Kaiser-Meyer-Olkin value was 0.76 and the
Barlett test of sphericity was 192.40. Two factors
emerged. Factor 1 had an eigenvalue of 2.64 and
explained 44% of the variance. The associated
symptoms were subjective anxiety (+0.79), auto-
nomic anxiety (+0.75), tension (+0.73) and
situational anxiety (+0.62). Factor 2 had an
eigenvalue of 0.97 and explained a further 16.3%
of the variance. Only panic (+0.73) was associated
with this factor. As there were only two patients
with panic attacks these were not considered as a
separate category of symptom. Irritability was not
associated with either of the factors and is hence
not considered as a symptom of anxiety in the
remaining analyses.
 ANXIETY IN DEMENTIA
Eighteen (16.5%) patients experienced one
anxiety symptom, seven (6.4%) patients experi-
enced two different anxiety symptoms, five (4.6%)
patients experienced three different anxiety symp-
toms and two (1.8%) experienced four different
symptoms. In total, 32 patients experienced one or
more anxiety symptom.
There was no significant difference between the
CAMCOG scores of patients with or without one
or more anxiety symptom (Mann-Whitney U test
2-0.15, p = 0.88), but there was a trend towards
an association with younger age (Mann-Whitney
U test Z - 1.89, p = 0.06). The presence of one or
more anxiety symptom was not associated with
gender (OR 1.38, 95% C10.51, 3.71) or the type of
dementia (Alzheimer’s disease vs vascular demen-
tia OR 1.08, 95% C1 0.21, 5.70), but there was a
trend towards an association with retained insight
(OR 2.86, 95% C1 0.97, 8.41).
Additional information was available regarding
the anxiety symptoms of 11 of the 14 patients with
two or more anxiety symptoms, where the
structured schedule had been annotated with
additional details. Two of these 11 patients
received a concurrent clinical diagnosis of depres-
sion. For both these patients the predominant
anxiety symptoms were congruent with the
depressed mood, including concerns of being a
burden to their partner and of being abandoned. A
further two patients experienced anxiety in relation
to psychotic symptoms. One suffered persecutory
delusions and the other had visual hallucinations.
Six of the remaining seven patients had specific
situational anxieties. These were related to situa-
tions where they feared they would embarrass
themselves because of their cognitive deficits. Two
of these patients had pronounced expressive
language difficulties and the others were worried
that they would forget who people were or would
forget important points that had been raised in the
conversation. Each of these six patients had insight
into their dementia.
DISCUSSION
The study population, although not representative
of patients with dementia in the community, did
comprise consecutively completed assessments
undertaken with standardized instruments at a
university memory clinic. Although the anxiety
symptoms were assessed using a standardized
schedule, no formal validation study was under-
989
taken. In addition, the number of items pertaining
to psychotic symptoms were limited, which might
have compromised the detection of concurrent
disorders. Given the difficulties of making a
diagnosis of anxiety disorder in this patient group,
the current study focused upon anxiety symptoms.
A principal components analysis was used to
inform the decision concerning the core anxiety
symptoms to be included.
Subjective anxiety and tension were particularly
common, occurring in 22% and 38% of the
patients respectively. Autonomic anxiety and
situational anxiety were also relatively frequent,
both occurring in more that 10% of patients.
Overall, 29.4% of the patients experienced one or
more anxiety symptoms. This is slightly lower
than the anxiety symptom prevalence rates
reported by Wands et ai. (1990) and Ballard el ai.
(1994). In the current study, sleep disturbance,
restlessness and irritability were not considered to
be core anxiety symptoms, which will have
reduced the number of people reported to
experience anxiety symptoms, although this would
seem an appropriate step in studying a population
with dementia where some of these symptoms
have a variety of causes.
None of the variables studied were significantly
associated with anxiety symptoms, although this
reflects a different pattern of associations to that
seen in the elderly population, where anxiety
disorders are more common among females
(Lindesay et al., 1989). Comparable to the study
of Ballard et al., (1994), there was a non-significant
trend towards an association with retained insight.
The absence of significant associations is probably
a reflection of the diversity of patients who suffer
from anxiety symptoms. Perhaps retention of
insight is an important association in a subgroup
of these patients. The descriptive information
suggests that there are three main categories of
anxious/demented patient, those with anxiety in
the context of depression, those with anxiety in the
context of psychosis and those with situational
anxiety. The latter group of patients have insight
into their condition and fear making errors in
interpersonal situations.
ACKNOWLEDGEMENTS
Thank you to the MRC Neurochemical Pathology
Unit for secretarial support.
990 C. BALLARD, A . BOYLE, C. BOWLER A N D J. LINDESAY
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