Journal of Affective Disorders 76 (2003) 261–265

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Brief report

Managing anxiety in people with dementia

A case series
a b c,
Afifa Qazi , Kuttalingam Shankar , Martin Orrell *
a
Warley Hospital, Warley Hill Brentwood Essex CM14 5 HQ , UK
b
Mental Health Unit, Princess Alexandra Hospital, Hamstel Road, Harlow, Essex CM20 1 QX UK
c
Department of Psychiatry and Behavioural Sciences, University College London, Wolfson Building, 48, Gower Street, London,
W1 N 8 AA UK

Received 16 October 2001; received in revised form 11 February 2002; accepted 15 February 2002

Abstract

Anxiety is common in people with dementia but little is known about its treatment. Seven cases with moderate / severe
dementia and significant clinical anxiety are described. Anxiety symptoms were measured using the RAID scale. Anxiety
was managed with pharmacological and psychosocial interventions. All patients showed a significant clinical improvement in
their anxiety and had a considerable reduction in their RAID scores. Assessment and effective treatment of anxiety in
dementia should improve patient’s quality of life and should become more established in good clinical practice. Further
research should include a randomised controlled trial of interventions to reduce anxiety.
 2003 Elsevier B.V. All rights reserved.

1. Introduction gression (Lyketsos and Steele, 1997). Anxiety in

Anxiety is commonly reported in people with
dementia with prevalence rates varying from 38% in
Alzheimer’s disease to as high as 72% in vascular
dementia (Ballard et al., 2000). Anxiety in this group
of patients causes considerable suffering to them and
their carers (Drinka et al., 1987). It often manifests
as motor restlessness, day / night disturbance, ir-
ritability, agitation (Reisberg et al., 1987) and ag-
*Corresponding author. Tel.: 1 44-1277-302-736; fax: 1 44-
1277-302-739.
E-mail address: m.orrell@ucl.ac.uk (M. Orrell).
these patients may be associated with very high
levels of social contact, problems in the patient / carer
relationship and high physical dependency (Orrell
and Bebbington, 1996). Teri et al. (1999) studied
523 community dwelling people with Alzheimer’s
disease and found anxiety symptoms occurred in
70% of the subjects. Anxiety significantly correlated
with impairment of activities of daily living, be-
havioural disturbances that included wandering, sex-
ual misconduct, verbal and physical aggression.
Some studies have reported that people with mild
dementia are more anxious than those in the later
stages (Ballard et al., 1994). This may well be due to
preserved insight in the early stages.

0165-0327 / 03 / $ – see front matter  2003 Elsevier B.V. All rights reserved.
doi:10.1016/S0165-0327(02)00074-5
262 A. Qazi et al. / Journal of Affective Disorders 76 (2003) 261–265
Little work has been done regarding the detection
and management of anxiety in this group of patients.
It has been difficult to identify (Forsell et al., 1993)
and so to treat. There is lack of specific and sensitive
instruments but new scales like the Rating for
Anxiety in Dementia (RAID) (Shankar et al., 1999)
aid in its identification and measuring change after
treatment. This is the first report of using RAID in
the context of treatment of anxiety in dementia
sufferers.
2. Method
The study was carried out on two dementia
assessment units in Essex. As part of their routine
assessment, dementia inpatients with symptoms of
anxiety (with or without depression) had their symp-
toms of anxiety and depression measured using
standardised scales appropriate for this group (RAID
and Cornell). Scales were administered mainly by
the nursing staff or by the psychiatric trainee. The
scales were scored based on the information obtained
from the clinical notes, the patient’s key worker and
the interview with the patient. Anxiety and depres-
sion were monitored using the above scales, over the
treatment period averaging 6 weeks.
2.1. Measures
Rating for Anxiety In Dementia (RAID) (Shankar
et al. (1999)): This scale has eighteen items that are
divided into four subgroups: worry, apprehension
and vigilance, motor tension, autonomic hyper-
sensitivity. Each item is then rated according to four
different grades, absent, mild or intermittent, moder-
ate and severe. A score of 11 and above indicates
significant clinical anxiety.
Cornell Scale for Depression in Dementia (Alex-
opoulos et al., 1988): this scale measures depression
in dementia patients. It is a global rating scale of
depressive symptoms in dementia including mood
related signs, behavioural disturbance, physical
signs, cyclic functions and ideational disturbance. It
has been demonstrated to be valid, reliable and
useful in clinical practice. Scores of 7 or more
indicate significant clinical depression.
3. Results
All the seven cases reported below had obvious
clinical manifestations of anxiety and scored 11 or
more on the RAID (see Table 1). Four patients had a
consultant diagnosis of Alzheimer’s disease, two had
vascular dementia and one had dementia secondary
to removal of a brain tumour. Five out of the seven
patients had been on a low dose antipsychotic;
however the pattern of improvement in anxiety
coincided with the commencement of antidepres-
sants. The cases and their outcomes are summarised
in Table 1.Two of the cases are described below.
3.1. Case No. 6
TD was a 79-year-old lady with vascular dementia
residing in a nursing home. She had initially settled
well in her nursing home, but gradually behavioural
problems started. The main concern was excessive
wandering. She would wander around the home and
enter into other residents’ rooms. This behaviour
occurred all through the day. She was, at times,
abusive and was becoming physically violent to-
wards the staff. She had a disturbed sleep–wake
cycle with day–night reversal. She was dehydrated
and walked with a shuffling gait due to the side
effects of the medication. She had significant clinical
anxiety and scored 22 on the RAID scale at the time
of admission to hospital. In the ward her neuroleptic
medication was stopped. She was started on Parox-
etine 20 mg. There was a dramatic change in her
behaviour. She stopped wandering around the ward.
She began to take an interest in the people around
her. Her sleep during the night improved. Her
anxiety and distress increased if left in the room
alone. Whilst in hospital she had the security of
others around her in a female dormitory, which
appeared to benefit her. She attended the OT activity
in the ward and, although she did not actively
participate, she again enjoyed the company. She was
discharged back to her nursing home with specific
recommendations regarding her environmental
needs. Her RAID score had fallen to 12 at the time
of discharge.
3.2. Case no. 7
Mr. KB was a 70 year-old man with dementia. He
Table 1
Case series of patients with dementia and anxiety–presentation and management
Case Age Sex Diagnosis and Clinical presentation RAID Cornell Intervention Change Outcome
no. MMSE score of anxiety Before/after Before/after

A. Qazi et al. / Journal of Affective Disorders 76 (2003) 261–265

1 89 M Alzheimer’s Restlessness, agitation, 19/4 11/4 Fluoxetine Cheerful, chatty, good Discharged to residential
disease disturbed sleep, poor 20 mg appetite, sleeping well home
7 appetite, withdrawn,
tearful on occasions

2 78 M Alzheimer’s Aggressive behaviour, 15/4 12/5 Lofepramine Calm and cooperative, Discharged to residential
disease restlessness, agitation, 140 mg bd not aggressive, sleeping home
6 poor sleep all night, bright and cheerful

3 78 F Alzheimer’s Persistent restlessness, 12/4 11/6 Sertraline Calm and settled, Discharged to EMI unit
disease agitation, disinhibited 100 mg cooperative, not disinhibited,
12 behaviour, wandering good sleep and appetite
up and down the ward

4 82 M Vascular Restlessness, agitation, 24/8 16/6 Fluoxetine Pleasant and cooperative, Discharged home
dementia aggressive towards staff 20 mg sleeping well, not aggressive
12

5 76 F Alzheimer’s Poor sleep, poor appetite, 14/3 12/4 Sertraline Good sleep and appetite, Discharged to a
disease withdrawn and apathetic 100 mg more communicative, taking residential home
18 at times, restless at others interest in things doing
small chores on the ward

6 79 F Vascular Wandering, abusive and 22/12 Scale Paroxetine Not wandering, less anxious Discharged to nursing
dementia aggressive behaviour, not 20 mg and distressed, good sleep, home
disturbed sleep/wake cycle used attending OT

7 76 M Dementia Irritability, pacing round 36/25 Scale Psychosocial Not as irritable, not wandering, Died in hospital
unspecified the house, wandering, not intervention more manageable in the ward due to
sleep disturbance used bronchopneumonia

263
264 A. Qazi et al. / Journal of Affective Disorders 76 (2003) 261–265
presented with sleep disturbance, was repeatedly
asking for reassurance from his wife and was
constantly complaining of headaches. He had epi-
sodes of irritability with pacing around the house and
on occasions walked out of his home and had to be
brought back by police. All these led to his admis-
sion to hospital. There he was able to wander within
the ward. He was given his own room instead of a
dormitory, which gave him a sense of personal
space. He was also given some night-time sedation.
The real breakthrough came when his wife presented
him with an electronic keyboard. He started to play
the tunes which he had learnt in the past. His
behaviour improved and he became more manage-
able on the ward. His RAID scale decreased by 9
points within a week (Table 1).
4. Discussion
This case series highlights the fact that anxiety
symptoms in dementia patients are identifiable,
measurable and can be treated. The patients re-
sponded to a range of interventions. Being in a
hospital environment with specialised experienced
staff could in itself have had some therapeutic effect.
Patients in this case series also responded to their
own specific environmental needs for example a
secure ward environment, presence of their own
space (private room), a place to wander and walk,
and presence of others (patients, staff). The medica-
tion used varied with the individual patient’s needs
but usually involved antidepressants.
The overlap between anxiety and depressive
symptoms, which has been described before (Fawcett
and Kravitz, 1983), was clearly obvious. All the
patients showed significant falls in their RAID and
Cornell scores after treatment. It is well known that
there is significant comorbidity between depression
and anxiety. In the Guys’ /Age concern survey,
Lindesay et al., 1989, found considerable comorbidi-
ty of depression with phobias and anxiety. In the
Epidemiological Catchment Area Study (ECA)
Reiger et al., 1998 reported nearly half (47.2%) of
those meeting the life-time criteria for major depres-
sion also met the criteria for comorbid anxiety
disorder. Some of the items in the Cornell scale are
present in the RAID scale as well. In their original
study, Shankar et al., 1999 reported that when these
common items were removed from the RAID scale it
correlated poorly with the Cornell scale. This sug-
gests that the RAID scale has items specific for
anxiety.
There are no controlled studies that have spe-
cifically looked into the management of anxiety in
dementia patients. Koder (1998) reported two case
reports in which cognitive behavioural therapy was
used. The techniques used were relaxation, distrac-
tion and cognitive restructuring. Nyth and Gottfries
(1990) reported the efficacy of citalopram in emo-
tional disorders inpatients with Alzheimer’s disease
and vascular dementia. The efficacy of cholinesterase
inhibitor drugs in improving anxiety as measured by
the Neuropsychiatric Inventory (Cummings et al.,
1994) has also been reported.
The case reports show a clear temporal relation-
ship between treatment of anxiety and improvement
in clinical presentation and outcome with decreased
RAID and Cornell scores. This paper indicates that
anxiety in dementia is treatable and thus highlights
the need for a well designed randomised control trial
to identify and treat anxiety in dementia sufferers.
Acknowledgements
We thank the nursing staff on the wards for
administering the scales to the patients. We also
thank Terri for her help and support.
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