How to manage anxiety in patients with Parkinson's disease dementia?

Managing Anxiety in Parkinson's Disease Dementia

Start with non-pharmacological interventions including cognitive-behavioral therapy and structured environmental modifications, and if pharmacological treatment becomes necessary, use SSRIs (citalopram 10 mg/day or sertraline 25-50 mg/day) as first-line agents, avoiding benzodiazepines due to fall risk and cognitive worsening. 1, 2

Initial Assessment and Identification

Before initiating any treatment, systematically investigate underlying medical causes that may be driving anxiety symptoms:

• Assess for pain, urinary tract infections, constipation, dehydration, and other infections (especially pneumonia) as these are major contributors to behavioral disturbances in dementia patients who cannot verbally communicate discomfort 3, 1
• Review all medications for anticholinergic effects that can worsen both cognitive symptoms and anxiety 1, 4
• Use structured assessment tools like the DICE approach or ABC (antecedent-behavior-consequence) charting to identify specific triggers and patterns of anxiety episodes 1
• Obtain detailed descriptions from caregivers about when anxiety occurs, what triggers it, and what happens afterward to understand the context 3

First-Line: Non-Pharmacological Interventions

Non-pharmacological approaches must be implemented first and documented as attempted before considering medications, as they have substantial evidence for efficacy without the mortality risks associated with pharmacological treatments 3, 1:

Environmental and Behavioral Strategies

• Establish predictable daily routines including regular physical exercise, consistent meal times, and fixed bedtime schedules to reduce anxiety 1
• Create a safe environment by removing hazards and installing safety features like grab bars 1
• Reduce excess environmental stimulation by minimizing glare, noise, and household clutter 1
• Use orientation aids such as calendars, clocks, and color-coded labels to help with navigation and reduce confusion 1
• Implement the "three R's" approach: repeat instructions, reassure the patient, and redirect attention to divert from anxiety-provoking situations 1

Communication Techniques

• Use simple language, explain procedures, and break complex tasks into manageable steps 1
• Maintain a calm tone and use soothing touch when communicating with the patient 1
• Allow adequate time for the patient to process information before expecting a response, as dementia patients need more time to understand and respond 3

Psychotherapeutic Interventions

• Cognitive-behavioral therapy (CBT) shows large effects for anxiety in Parkinson's disease and should be offered when available 5, 6
• CBT involves helping the patient overcome behavioral avoidance associated with anxiety and challenge unhelpful negative cognitions 6
• Consider a multimodal approach utilizing psychotherapeutic interventions along with pharmacologic therapies when feasible 2

Second-Line: Pharmacological Treatment

Medications should only be considered when non-pharmacological approaches have been ineffective or when there is significant risk of harm 1, 4:

SSRI Selection and Dosing

SSRIs are the preferred first-line pharmacological option for anxiety in Parkinson's disease dementia:

• Citalopram: Start at 10 mg/day, maximum 40 mg/day - well tolerated though some patients experience nausea and sleep disturbances 3
• Sertraline: Start at 25-50 mg/day, maximum 200 mg/day - well tolerated with less effect on metabolism of other medications 3
• Evaluate response within 4 weeks of initiating treatment using quantitative measures 3, 1
• If no clinically significant response after 4 weeks at adequate dose, taper and withdraw the medication 3

The evidence supporting SSRIs comes from uncontrolled studies showing effectiveness for anxiety in PD, though anxiety outcomes were secondary measures 2. There are no controlled studies specifically for anxiety in PD, but the safety profile and modest efficacy make them the preferred choice 7.

Alternative Pharmacological Options

If SSRIs fail or are not tolerated:

• Trazodone: Start at 25 mg/day, maximum 200-400 mg/day in divided doses 3
• Use caution in patients with premature ventricular contractions due to risk of orthostatic hypotension and falls 3

Dopaminergic Optimization

For anxiety associated with motor fluctuations and wearing-off periods:

• Anxiety often improves with L-Dopa, especially in patients with high levels of anxiety during off-periods 7
• Decreasing off-periods is important for managing anxiety in patients with motor fluctuations 7
• Low-dose transdermal rotigotine (4 mg/day) may improve anxiety during wearing-off without worsening cognitive and behavioral symptoms 8

Medications to Avoid

Benzodiazepines

Do not use benzodiazepines as first-line treatment for anxiety in Parkinson's disease dementia:

• Benzodiazepines increase the risk of falls, confusion, cognitive impairment, and paradoxical agitation in approximately 10% of elderly patients 3
• Only one study (bromazepam) showed efficacy for anxiety in PD, but usage is limited by these significant risks 2, 7
• Benzodiazepines can increase delirium incidence and duration 3

Antipsychotics

Reserve antipsychotics only for severe behavioral disturbances with psychotic features (hallucinations, delusions) causing significant distress:

• All antipsychotics increase mortality risk (1.6-1.7 times higher than placebo) in elderly dementia patients 3
• Use only at the lowest effective dose for the shortest possible duration with daily reassessment 3
• Discuss increased mortality risk, cardiovascular effects, and expected benefits with the patient and surrogate decision maker before initiating 3

Other Medications to Avoid

• Avoid medications with significant anticholinergic effects as they worsen cognitive symptoms 1, 4
• Do not use thioridazine, chlorpromazine, or conventional antipsychotics like haloperidol as first-line management 4

Monitoring and Reassessment

• Evaluate response within 30 days of initiating pharmacological treatment 1, 4
• Consider referral to a mental health specialist if minimal or no improvement is observed 1
• Gradually reduce or discontinue medications after 6 months of symptom stabilization 1
• Regularly reassess the need for continued medication as neuropsychiatric symptoms fluctuate throughout dementia progression 1
• Monitor for medication side effects including falls, metabolic changes, and cognitive worsening 3

Common Pitfalls to Avoid

• Do not rely solely on medications without implementing non-pharmacological strategies 1, 4
• Do not underestimate the role of pain and discomfort as causes of anxiety 1
• Do not use inappropriate communication techniques such as complex multi-step commands or harsh tones 1
• Do not fail to monitor for medication side effects, which can sometimes exacerbate behavioral symptoms 1
• Do not continue medications indefinitely without reassessment 3