International Journal of Psychiatry in Clinical Practice, 2005; 9(4): 299 /300
CASE REPORT
Anxiety can be a harbinger of early onset dementia
ASHOK K. JAINER, DEMI ONALAJA & FABIDA NOUSHAD The Caludon Centre, Coventry Primary Care NHS Trust, Coventry, UK
Abstract We report an interesting case study of a 58-year-old woman who had early onset dementia which initially presented with marked features of anxiety that masked her cognitive impairment. She was treated for anxiety for about 2 years. Her anxiety symptoms caused hindrance in detecting dementia at the early stage.
Key Words: Dementia Mini mental statement examination, Alzheimer’s disease, neurodegenerative disorder, anxiety
Introduction Alzheimer’s disease (AD) is characterised by a progressive decline in mental abilities as a result of disease of the brain, usually of a chronic or progressive nature, in which there is disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language and judgement [1]. It is estimated that there are approximately 700,000 people with dementia in England and Wales, of whom AD sufferers comprise 400,000 [2]. The onset of AD is slow and insidious, often presenting with neuropsychiatric symptoms [3], such as aggression, agitation, depression, psychosis and anxiety, making an accurate diagnosis a difficult task at the outset. Early diagnosis of AD is important from a therapeutic point of view as most of the cognitive enhancers available today are beneficial only in patients with mild to moderate AD. Case report Mrs X, a 58-year-old woman, was referred by her general practitioner to the psychiatric services in April 2002 with a 2.5-year history of anxiety symptoms. She was accompanied by her husband and presented with symptoms of anxiety, such as shakes, palpitations and sweating, occurring in bouts and lasting from 45 minutes to an hour. There were no identifiable precipitants for the anxiety attacks. She was frightened of being alone. There were no biological features of depression. Family history
revealed that her father and sibling had anxiety problems. She had a normal childhood. She had been treated with the serotonin reuptake inhibitor, citalopram, 20 mg once a day, 2 months prior to the clinic visit. Her Mental State Examination was normal except for occasional restlessness. She was continued on citalopram. Four weeks later, she reported that her anxiety attacks had reduced to one in 10 days. Her husband died few months later. During subsequent visits, she started complaining of memory problems. She was finding it difficult to cope with Activities of Daily Living (ADL). Her family also raised concerns about her forgetfulness and inability to recognise them. They also mentioned that her memory problems must have started long before her husbands’ death and that he must have covered up her lapses in memory in the previous meetings. Her memory problem was now evident. Her short-term memory was impaired. She scored 16/30 on the Mini Mental State Examination (MMSE). It was reported that she was unable to cook, shop and find her way back home. She was suspected to have early onset dementia and was urgently referred to the Young Onset Dementia Team. Assessment by the Young Onset Dementia Team showed that she was forgetting events, becoming repetitive, misplacing valuable possessions like her purse, mismanaging finances and burning food. She had lost weight due to disorganised eating patterns. She was disoriented in time, place and person. Her language functions had also declined. She was aggressive towards family members and her mood
Correspondence: Ashok K. Jainer, Consultant in General Adult Psychiatry, The Caludon Centre, Coventry Primary Care NHS Trust, Walsgrave, Coventry CV2 2TE, UK. E-mail: [email protected]
(Received 4 October 2004; accepted 15 June 2005) ISSN 1365-1501 print/ISSN 1471-1788 online # 2005 Taylor & Francis DOI: 10.1080/13651500500231612
300
A. K. Jainer et al.
was labile. She scored 10/30 in MMSE. Brain MRI scans done reported severe atrophy affecting the supratentorial brain. The atrophy was global but with more involvement of the temporal lobe and hippocampus. There were hardly any ischaemic changes. The overall appearance was consistent with a fairly advanced Alzheimer’s type neurodegenerative disorder. Discussion In the early stages, dementia may present with neurotic disorders such as anxiety disorder, symptoms of obsessive/compulsive disorder, or (rarely) dissociative disorders. More commonly, the neurotic disorders cause subjective cognitive impairment, which may be the presenting symptom [4]. Dementia is associated with higher rates of anxiety, unrelated to severity of cognitive deficit. This anxiety may be associated with the implications of diagnosis in those patients who retain insight. Porter et al [5] have also shown that anxiety is common among patients with diverse forms of dementia. Their study assessed the cross-sectional prevalence and characteristics of anxiety among patients with AD, as compared with patients with fronto-temporal dementia (FTD), patients with vascular dementia (VaD), and normal control subjects. In addition, they explored the relationships between cognitive status (as indicated by the MMSE) and anxiety. Anxiety was reported more commonly in patients with VaD and FTD than in patients with AD. In patients with AD, anxiety was inversely related to MMSE score (i.e. worse with more severe dementia), and was more prevalent among patients with a younger age of onset (under age 65). Before drug treatment for anxiety is considered, the possibility of dementing illness must be taken into account [6]. Given that dementia may present with anxiety symptoms in the early stages, a high index of suspicion is required to diagnose and manage this condition. As Mrs X’s husband covered up her lapses in memory in previous meetings, this might have resulted in initial diagnostic failure. We therefore recommend that an exploration of a patient without their carer would help in the early detection of the organic origin of an affective or anxiety disorder. In particular, we now have cognitive enhancers licensed for mild to moderate AD. Livingston and Katona [7] have shown that very small numbers of patients need to be treated with cholinesterase inhibitors in order to postpone or reverse
deterioration in one of them. Therefore, it is imperative to make an early diagnosis in order for these groups of patients to benefit from these drugs, as AD is common but distressing and associated with inexorable deterioration. Keypoints . Dementia is a common cause of disability and dependency in our society, with Alzheimer’s disease (AD) alone being the fourth most common cause of death in the western world . Presentation with neuropsychiatric symptoms such as aggression, agitation, depression, psychosis and anxiety is common . Dementia is associated with higher rates of anxiety, unrelated to severity of cognitive deficit . In AD, anxiety is most common in those with more severe cognitive deterioration and an early age at onset (under age 65) . Before drug treatment for anxiety is considered, the possibility of dementing illness must be taking into account. Statement of interest The authors have no conflict of interest with any commercial or other associations in connection with the submitted article.
References [1] Naidoo M, Bullock R. An integrated care pathway for dementia. Harcourt Health Communications 2001;1 /6. [2] NICE. Technology Appraisal Guidance, No. 19. Guidance on the use of Donepezil, Rivastigmine and Galantamine for the treatment of Alzheimer’s Disease; 2001. p 2. [3] Aarsland D, Cummings JL, Yenner G, Miller B. Relationship of aggressive behaviour to other neuropsychiatric symptoms in patients with Alzheimer’s disease. Am J Psychiatry 1996; 153(2):243 /7. [4] Gelder MG, Lopez-Ibor JJ, Andraesen NC. New Oxford Textbook of Psychiatry, Vol. 2. 2002. p 1652, Oxford University Press. [5] Porter VR, Buxton WG, Fairbanks LA, et al. Frequency and characteristics of anxiety among patients with Alzheimer’s disease and related dementias. J Neuropsychiatry Clin Neurosci 2003;15:180 /6, John Wiley & Sons Ltd. [6] Copeland JRM, Abou-Saleh MT, Blazer DG. Principles and Practice of Geriatric Psychiatry. 1994. p 742. [7] Livingston G, Katona C. How useful are cholinesterase inhibitors in the treatment of Alzheimer’s disease? A number needed to treat analysis. Int J Geriatr Psychiatry 2000;15: 203 /7. /
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CASE REPORT
Anxiety can be a harbinger of early onset dementia
ASHOK K. JAINER, DEMI ONALAJA & FABIDA NOUSHAD The Caludon Centre, Coventry Primary Care NHS Trust, Coventry, UK
Abstract We report an interesting case study of a 58-year-old woman who had early onset dementia which initially presented with marked features of anxiety that masked her cognitive impairment. She was treated for anxiety for about 2 years. Her anxiety symptoms caused hindrance in detecting dementia at the early stage.
Key Words: Dementia Mini mental statement examination, Alzheimer’s disease, neurodegenerative disorder, anxiety
Introduction Alzheimer’s disease (AD) is characterised by a progressive decline in mental abilities as a result of disease of the brain, usually of a chronic or progressive nature, in which there is disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language and judgement [1]. It is estimated that there are approximately 700,000 people with dementia in England and Wales, of whom AD sufferers comprise 400,000 [2]. The onset of AD is slow and insidious, often presenting with neuropsychiatric symptoms [3], such as aggression, agitation, depression, psychosis and anxiety, making an accurate diagnosis a difficult task at the outset. Early diagnosis of AD is important from a therapeutic point of view as most of the cognitive enhancers available today are beneficial only in patients with mild to moderate AD. Case report Mrs X, a 58-year-old woman, was referred by her general practitioner to the psychiatric services in April 2002 with a 2.5-year history of anxiety symptoms. She was accompanied by her husband and presented with symptoms of anxiety, such as shakes, palpitations and sweating, occurring in bouts and lasting from 45 minutes to an hour. There were no identifiable precipitants for the anxiety attacks. She was frightened of being alone. There were no biological features of depression. Family history
revealed that her father and sibling had anxiety problems. She had a normal childhood. She had been treated with the serotonin reuptake inhibitor, citalopram, 20 mg once a day, 2 months prior to the clinic visit. Her Mental State Examination was normal except for occasional restlessness. She was continued on citalopram. Four weeks later, she reported that her anxiety attacks had reduced to one in 10 days. Her husband died few months later. During subsequent visits, she started complaining of memory problems. She was finding it difficult to cope with Activities of Daily Living (ADL). Her family also raised concerns about her forgetfulness and inability to recognise them. They also mentioned that her memory problems must have started long before her husbands’ death and that he must have covered up her lapses in memory in the previous meetings. Her memory problem was now evident. Her short-term memory was impaired. She scored 16/30 on the Mini Mental State Examination (MMSE). It was reported that she was unable to cook, shop and find her way back home. She was suspected to have early onset dementia and was urgently referred to the Young Onset Dementia Team. Assessment by the Young Onset Dementia Team showed that she was forgetting events, becoming repetitive, misplacing valuable possessions like her purse, mismanaging finances and burning food. She had lost weight due to disorganised eating patterns. She was disoriented in time, place and person. Her language functions had also declined. She was aggressive towards family members and her mood
Correspondence: Ashok K. Jainer, Consultant in General Adult Psychiatry, The Caludon Centre, Coventry Primary Care NHS Trust, Walsgrave, Coventry CV2 2TE, UK. E-mail: [email protected]
(Received 4 October 2004; accepted 15 June 2005) ISSN 1365-1501 print/ISSN 1471-1788 online # 2005 Taylor & Francis DOI: 10.1080/13651500500231612
300
A. K. Jainer et al.
was labile. She scored 10/30 in MMSE. Brain MRI scans done reported severe atrophy affecting the supratentorial brain. The atrophy was global but with more involvement of the temporal lobe and hippocampus. There were hardly any ischaemic changes. The overall appearance was consistent with a fairly advanced Alzheimer’s type neurodegenerative disorder. Discussion In the early stages, dementia may present with neurotic disorders such as anxiety disorder, symptoms of obsessive/compulsive disorder, or (rarely) dissociative disorders. More commonly, the neurotic disorders cause subjective cognitive impairment, which may be the presenting symptom [4]. Dementia is associated with higher rates of anxiety, unrelated to severity of cognitive deficit. This anxiety may be associated with the implications of diagnosis in those patients who retain insight. Porter et al [5] have also shown that anxiety is common among patients with diverse forms of dementia. Their study assessed the cross-sectional prevalence and characteristics of anxiety among patients with AD, as compared with patients with fronto-temporal dementia (FTD), patients with vascular dementia (VaD), and normal control subjects. In addition, they explored the relationships between cognitive status (as indicated by the MMSE) and anxiety. Anxiety was reported more commonly in patients with VaD and FTD than in patients with AD. In patients with AD, anxiety was inversely related to MMSE score (i.e. worse with more severe dementia), and was more prevalent among patients with a younger age of onset (under age 65). Before drug treatment for anxiety is considered, the possibility of dementing illness must be taken into account [6]. Given that dementia may present with anxiety symptoms in the early stages, a high index of suspicion is required to diagnose and manage this condition. As Mrs X’s husband covered up her lapses in memory in previous meetings, this might have resulted in initial diagnostic failure. We therefore recommend that an exploration of a patient without their carer would help in the early detection of the organic origin of an affective or anxiety disorder. In particular, we now have cognitive enhancers licensed for mild to moderate AD. Livingston and Katona [7] have shown that very small numbers of patients need to be treated with cholinesterase inhibitors in order to postpone or reverse
deterioration in one of them. Therefore, it is imperative to make an early diagnosis in order for these groups of patients to benefit from these drugs, as AD is common but distressing and associated with inexorable deterioration. Keypoints . Dementia is a common cause of disability and dependency in our society, with Alzheimer’s disease (AD) alone being the fourth most common cause of death in the western world . Presentation with neuropsychiatric symptoms such as aggression, agitation, depression, psychosis and anxiety is common . Dementia is associated with higher rates of anxiety, unrelated to severity of cognitive deficit . In AD, anxiety is most common in those with more severe cognitive deterioration and an early age at onset (under age 65) . Before drug treatment for anxiety is considered, the possibility of dementing illness must be taking into account. Statement of interest The authors have no conflict of interest with any commercial or other associations in connection with the submitted article.
References [1] Naidoo M, Bullock R. An integrated care pathway for dementia. Harcourt Health Communications 2001;1 /6. [2] NICE. Technology Appraisal Guidance, No. 19. Guidance on the use of Donepezil, Rivastigmine and Galantamine for the treatment of Alzheimer’s Disease; 2001. p 2. [3] Aarsland D, Cummings JL, Yenner G, Miller B. Relationship of aggressive behaviour to other neuropsychiatric symptoms in patients with Alzheimer’s disease. Am J Psychiatry 1996; 153(2):243 /7. [4] Gelder MG, Lopez-Ibor JJ, Andraesen NC. New Oxford Textbook of Psychiatry, Vol. 2. 2002. p 1652, Oxford University Press. [5] Porter VR, Buxton WG, Fairbanks LA, et al. Frequency and characteristics of anxiety among patients with Alzheimer’s disease and related dementias. J Neuropsychiatry Clin Neurosci 2003;15:180 /6, John Wiley & Sons Ltd. [6] Copeland JRM, Abou-Saleh MT, Blazer DG. Principles and Practice of Geriatric Psychiatry. 1994. p 742. [7] Livingston G, Katona C. How useful are cholinesterase inhibitors in the treatment of Alzheimer’s disease? A number needed to treat analysis. Int J Geriatr Psychiatry 2000;15: 203 /7. /
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