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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 68-70

The missing link between late-onset separation anxiety and dementia


1 Department of Psychiatry, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
2 Department of Radio Diagnosis, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India

Date of Web Publication27-Jun-2018

Correspondence Address:
Lokesh Kumar Singh
Department of Psychiatry, All India Institute of Medical Sciences, Raipur - 492 099, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jgmh.jgmh_23_17

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  Abstract 


Relation of behavioral and psychological symptoms with dementia has several implications. They predict treatment and prognosis in patients. Anxiety and its association as a psychological symptom despite being well known is not addressed properly in clinical settings. Although generalized anxiety disorder is most commonly seen in patients with dementia, some of them might also present with late-onset separation anxiety. Presentation of separation anxiety in the index patient signifies the fact that atypical age of onset, acuteness of presentation points toward an underlying organic etiology. Patients with such clinical features should be thoroughly assessed for dementia. Clinicians should be aware of the association between separation anxiety and organic deficits.

Keywords: Dementia, late-onset separation anxiety, sertraline


How to cite this article:
Singh LK, Mamidipalli SS, Bodhey NK, Nandan NK, Chandrakar N. The missing link between late-onset separation anxiety and dementia. J Geriatr Ment Health 2018;5:68-70

How to cite this URL:
Singh LK, Mamidipalli SS, Bodhey NK, Nandan NK, Chandrakar N. The missing link between late-onset separation anxiety and dementia. J Geriatr Ment Health [serial online] 2018 [cited 2018 Dec 18];5:68-70. Available from: http://www.jgmh.org/text.asp?2018/5/1/68/235367




  Introduction Top


The association between dementia and behavioral and psychological symptoms popularly abbreviated as BPSD is well known. Patients presenting with dementia may go on to develop behavioral, psychological symptoms in the advanced phases of disease or dementia may be the later presentation with behavioral, psychological symptoms taking the forefront.[1] Earlier detection of dementia is needed in order to stop the brain degeneration at least in the dementias due to reversible causes. Varied clinical presentation might sometimes lead to under-recognition of the cognitive deficits. Vascular dementia in particular needs mention in this respect as it has wide interindividual variation.[2] The prevalence of anxiety disorders range from 5% to 21% in dementia. Furthermore, among the subtypes of dementia, vascular dementia has highest comorbidity with anxiety disorders. Most common anxiety disorder diagnosed in these patients is generalized anxiety disorder.[3] To the best of our knowledge, none of the current studies show any association between adult separation anxiety disorder and vascular dementia.

The aim of the current case report is to elaborate how separation anxiety presenting at adulthood might mask the underlying dementia and to discuss its implications.


  Case Report Top


We hereby report the case of a 68-year-old female with a premorbidly well-adjusted personality. Her illness started 3 years back when family members noticed that unlike her previous self, the patient started to call her husband often to know about his whereabouts. She would be preoccupied with the thought that some harm will befall him. She would occasionally deny him from going to the office and would ask him to stay with her. However, initially, she would be convinced by her husband's reassurance. However, she continued to do her daily activities and would enjoy doing prayer and attending religious gatherings like her previous self. Family members deny any persistent sadness, pessimistic views, autonomic symptoms, or feeling of being on edge. Over the next 2 years, her worries regarding separation from husband worsened. Apart from calling him repeatedly, she would follow him till the door and request him not to leave her. Furthermore, she started to have difficulty in performing daily activities. She would not be able to take bath, change clothes, or eat food by herself and had to be helped by her husband. She would not interact properly with other family members apart from her husband and would only respond to the questions asked unlike previous. She would have difficulty in planning about monetary issues at home along with difficulty in handling money. Although she would understand simple commands given by family members, at times, she would get distracted and start staring in the air and lost track of the conversation. Occasionally, she would also state worries about the safety of family members but would be more preoccupied about husband leaving her alone. However, during this period, the patient never looked sad and neither the anxiety would persist throughout the day. Gradually, she started following him to the office also and had to be locked in the home. During that period of separation from the husband, she would be restless and would keep moving about in the home waiting for her husband's arrival. However, her biological functions were adequate at that time.

Current consultation was taken due to the sudden worsening of the above symptoms over the past 1 month. She now becomes more dysfunctional due to the anxiety whenever her husband would leave her alone and she would follow him even to the bathroom. She was extremely fearful of being alone and had constant need to be with her spouse. However, when her husband asked her why she was worried regarding being left without him, she would not explain. Also she wouldn't get reassured easily unlike her previous self. She would not allow him to even go to work and would either resorted to self-harm by biting her hands to make him return home or by biting him if he considered leaving somewhere without her. She could not go anywhere without him and her anxiety started impairing her personal and social life and brought conflict in the family.

Throughout the period, her mood remained predominantly anxious and at times perplexed. History did not suggest any delusions or hallucinations, focal neurological deficits, impaired visuospatial skills, agnosia, and Parkinsonian features in the patient. She had no previous documented history of separation anxiety disorder in childhood or any anxiety disorder in past. She had one episode of depression in the past about 9 years ago for which she took treatment and improved. She had no past medical comorbidity.

On examination, her vitals were stable. She was well oriented to time, place, and person. She was calm when her husband was near her but got extremely anxious and agitated when he was out of her sight and tried to follow him. She did not quote any reason for the behavior when was posed with open-ended questions. Even when she was asked leading question as to whether she is convinced about the fact that her husband will leave her she did not provide proper explanation. Her mini-mental state examination was done which came out to be 16 out of 30.

After the history taking and examination, we considered the possibilities of separation anxiety, generalized anxiety disorder, panic disorder, agoraphobia along with dementia as per Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The possible diagnoses of all the anxiety disorders were however subsumed under the category of BPSD. Her anxiety and fear of staying alone stems from the separation from him rather than fear of being escape from crowded places and insecurity about her husband's love, hence ruling out agoraphobia and borderline personality disorder. She had episodes of agitation only when her figure of attachment was away and subsided on his return and she did not anticipate or worry about further such episode unlike panic disorder. Her chief preoccupation was fear of separation contrary to generalized anxiety disorder where the subject of anxiety is wide spectrum. In case of the diagnosis of dementia subtype, the onset of illness, absence of predominant memory deficits, and step-wise progression with abrupt worsening of symptoms suggested a vascular etiology of the illness despite the absence of focal neurological deficits.

After detailed evaluation, we considered the possibilities of separation anxiety and vascular dementia. She was admitted in psychiatry ward, and considering her behavior in the form of biting hands and extreme restlessness/agitation, she was started on haloperidol, promethazine, and lorazepam to which she responded well. The patient was rated on instrumental activities of daily living scale in which she scored 2 points which indicate significant impairment.[4] On neuropsychiatric inventory [5] used to assess comorbid psychopathology in patients with dementia, she screened positive for anxiety, irritability, and apathy and screened negative for other seven domains. Her total score was 18 and care giver distress was scored 14. However, neuropsychological assessment could not be done in the patient as she was not cooperative. During the ward stay, following investigations were done – her complete blood count, thyroid functions, B12, folate levels, serum electrolytes, and renal function tests. All of these were within normal limits apart from Hb – 10.5 g/dl. Contrast-enhanced computed tomography was performed which suggested acute to subacute infarct in left frontal periventricular white matter and age-related changes in cerebrum and cerebellum. T2W magnetic resonance imaging (MRI) showed a hyperintense focus involving the left caudocapsular region consistent with old infarct [Figure 1]. Neurology consultation was taken, and tablet ecosprin 75 mg and tablet atorvastatin 20 mg were started.
Figure 1: T2W magnetic resonance imaging showed a hyperintense focus involving the left caudocapsular region consistent with old infarct

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During the admission in view of significant anxiety at presentation, the patient was started on sertraline at low doses (25 mg), and after a week, it was increased to 50 mg/d (with monitoring of electrolytes) along with low dose clonazepam 1 mg/d. Because of associated irritability, agitation patient was started on olanzapine which was gradually increased to 10 mg/d. Nonpharmacological measures that were implemented were family psychoeducation, education about measures of environmental safety, reality orientation, medication supervision, addressing care giver burnout, and providing support. She is under our follow-up for the past 6 months. Currently, there is significant reduction in her agitation, irritability, and anxiety of staying alone. She now allows her husband to go out without troubling him and can be easily reassured. However, there is not much improvement in her cognitive functions and impaired activities of daily living. Further plan is to keep the patient in long-term follow-up and to tailor the treatment depending on the course of her illness.


  Discussion Top


The current case throws light on few important issues. First of all, we must admit the fact that in the first cross-sectional examination, the patient's history and mental state only lead us to the diagnosis of adult separation anxiety disorder. However, postadmission, details regarding her impaired activities of daily living, executive dysfunction, inattention, onset, and progression lead us to the diagnosis of dementia. Although in the current existing literature, association between adult separation anxiety with other anxiety disorders and mood disorders has been well replicated.[6],[7],[8] Our case is unique. To the best of our knowledge, this is the first case where the patient with dementia presented with symptoms of separation anxiety. Moreover, the presentation of separation anxiety in our patient is much more than the fear of being alone commonly seen as a part of dementia/depression. Despite the high prevalence of anxiety disorders/symptoms as a part of BPSD in vascular dementia, anxiety has received little consideration. It is important to recognize and treat anxiety in these patients because it is related to poor quality of life, behavioral disturbances, and limitations in activities of daily living.[3],[9]

Although the diagnosis of vascular dementia/major neurocognitive disorder due to vascular etiology in our case was made with substantial confidence [10] (DSM-5), diagnosis of separation anxiety is only probable. The reasons for not being able to make a definitive diagnosis are multiple. Furthermore, her separation anxiety and other behaviors can be explained in terms of BPSD. They were preceding the onset of dementia as is the usual case with depression and dementia. The difficulty in diagnosing anxiety disorder in dementia comes because of similar presentation of both the conditions. As per DSM-5, patients with adult separation anxiety disorder have more of cognitive symptoms compared to their childhood counterpart along with longer duration of symptoms for 6 months. However, patients with dementia because of the cognitive impairment often have difficulty in communicating their symptoms like in the index patient. As a result, diagnosis should be based on merely behavioral observations.[3] Few case reports in the past also suggested the association between separation anxiety and abnormalities in the amygdale.[11],[12] However, none of the existing literature to the best of our knowledge showed a relation between separation anxiety and infarct in the caudocapsular region.

Hence, patients presenting with features of first onset of separation anxiety at a later date should be thoroughly evaluated for underlying dementia and organic etiology. Failure to identify will often lead to delay in diagnosis and treatment of the primary condition like dementia leading to poor prognosis in these patients. High index of suspicion should be kept in mind and neuroimaging should be considered in all the patients with such a profile. Further studies should be conducted to develop diagnostic criteria for separation anxiety specific to patients with dementia like the Starkstein criteria [13] for generalized anxiety disorder.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chiu MJ, Chen TF, Yip PK, Hua MS, Tang LY. Behavioral and psychologic symptoms in different types of dementia. J Formos Med Assoc 2006;105:556-62.  Back to cited text no. 1
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2.
Smith EE. Clinical presentations and epidemiology of vascular dementia. Clin Sci (Lond) 2017;131:1059-68.  Back to cited text no. 2
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3.
Seignourel PJ, Kunik ME, Snow L, Wilson N, Stanley M. Anxiety in dementia: A critical review. Clin Psychol Rev 2008;28:1071-82.  Back to cited text no. 3
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4.
Lawton MP, Brody EM. Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist 1969;9:179-86.  Back to cited text no. 4
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5.
Cummings JL. The neuropsychiatric inventory: Assessing psychopathology in dementia patients. Neurology 1997;48:S10-6.  Back to cited text no. 5
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6.
Manicavasagar V, Marnane C, Pini S, Abelli M, Rees S, Eapen V, et al. Adult separation anxiety disorder: A disorder comes of age. Curr Psychiatry Rep 2010;12:290-7.  Back to cited text no. 6
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7.
Cassano GB, Rotondo A, Maser JD, Shear MK, Frank E, Mauri M, et al. The panic-agoraphobic spectrum: Rationale, assessment, and clinical usefulness. CNS Spectr 1998;3:35-48.  Back to cited text no. 7
    
8.
Pini S, Abelli M, Shear KM, Cardini A, Lari L, Gesi C, et al. Frequency and clinical correlates of adult separation anxiety in a sample of 508 outpatients with mood and anxiety disorders. Acta Psychiatr Scand 2010;122:40-6.  Back to cited text no. 8
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9.
Ballard C, Neill D, O'Brien J, McKeith IG, Ince P, Perry R, et al. Anxiety, depression and psychosis in vascular dementia: Prevalence and associations. J Affect Disord 2000;59:97-106.  Back to cited text no. 9
    
10.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington, DC: American Psychiatric Publishing Incorporated; 2013.  Back to cited text no. 10
    
11.
Chen HC, Lin CF, Lee YC. The right amygdalar tumor presenting with symptoms of separation anxiety disorder (SAD): A case report. Neurocase 2015;21:268-70.  Back to cited text no. 11
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12.
Redlich R, Grotegerd D, Opel N, Kaufmann C, Zwitserlood P, Kugel H, et al. Are you gonna leave me? Separation anxiety is associated with increased amygdala responsiveness and volume. Soc Cogn Affect Neurosci 2015;10:278-84.  Back to cited text no. 12
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13.
Starkstein SE, Jorge R, Petracca G, Robinson RG. The construct of generalized anxiety disorder in Alzheimer disease. Am J Geriatr Psychiatry 2007;15:42-9.  Back to cited text no. 13
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