Treating anxiety in dementia

This article is the fourth in a series aimed at helping people with dementia, their families and care staff address some of the common issues and questions in relation to medications often prescribed to people with dementia. Stuart Kennedy considers the use of non-pharmacological interventions and medication in treating anxiety for a person with dementia.

Kennedy, S. (2026) ‘Treating anxiety in dementia’, Journal of Dementia Care, 34(2) pp. 38-45.

Stuart Kennedy is an Admiral Nurse and works on Dementia UK’s Admiral Nurse Dementia Helpline. He has held a non-medical prescribing qualification for 22 years. The article, and the series it is part of, have been co-written and edited by Stuart Kennedy with Karen Harrison Dening, Honorary Research Fellow (Emeritus), Dementia UK.

Common questions

Themes common across callers to Dementia UK’s Admiral Nurse Dementia Helpline in relation to treating anxiety in a person with dementia include:

• Can anxiety occurring in a person with dementia be managed successfully without medication?
• What medications are prescribed to treat anxiety in people with dementia?
• What are the main side effects and risks of these medications?

What is anxiety?

Anxiety is a word that probably dates to the 1500s describing an apprehension, a sense of unease or dread caused by danger, perceived or real.

Although the term is often pathologised, anxiety also describes an expected reaction to events. Fear should be distinguished from anxiety in as much as fear is generally a response to a direct or real threat, whereas anxiety is usually a response to a possible threat. There are occasions in which anxiety is not only “normal” but useful. Anxiety before an exam or interview is often short-lived and may serve to maintain alertness and problem-solving. It becomes problematic (in common with most mental health conditions) when it is disproportionate, difficult to control, intense and/or affecting daily life. It may occur because of something physically specific to the individual (caffeine, alcohol, thyroid disorders), alongside other mental health conditions/diagnoses (depression, post-traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), etc.), or in isolation. According to the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders or DSM-5 (American Psychiatric Association, 2013) problematic anxiety can include generalised anxiety disorder (GAD), agoraphobia, panic disorder, specific phobia, social anxiety disorder, and separation anxiety.

As a mental health symptom, anxiety can be considered acute or chronic, and is more common in women (Slee et al., 2020).

The physiology of anxiety is a complex interplay of threat detection starting with the amygdala. The amygdala is part of the brain’s limbic system which manages emotional processing. This leads to the hypothalamus (also part of the limbic system) setting off a hormonal response involving adrenaline which instigates the “fight or flight” stress response (increased blood pressure, pulse etc) (see Figure 1).

Brain function relies heavily on neurotransmitters (see glossary). Gamma Aminobutyric Acid (GABA) is one of these and when activated, can slow the brain and reduce anxiety/stress.

General anxiety disorder (GAD) and depression frequently co-exist and overlap in some of the key symptoms. Judd et al (1998) suggested that 62% of people with GAD also have at least one episode of major depression in their lifetime.

Anxiety as experienced and expressed in a person with dementia

Although dementia is not considered to be a mental health condition it can lead to changes in mood and other symptoms such as depression and anxiety. The prevalence of anxiety symptoms among people living with dementia is thought to be around 40% (Mendez, 2021).

Diagnosing anxiety in a person with dementia can be challenging and requires a thorough review of physical factors and existing prescribed medications. Where language/word-finding difficulties exist (commonly referred to as dysphasia) consultation with a Speech and Language Therapist may prove of value. Anxiety, whilst coexisting with dementia, may also predate the diagnosis of dementia. Assessments leading to mental health and dementia diagnoses often enquire about the person’s traits and personality leading up to the point of assessment (commonly referred to as “pre-morbid personality”). At this stage it can guide eventual diagnosis by establishing a clearer baseline against which to compare past with present.

Outside of the clinical diagnostic setting, pre-morbid anxiety may also be relevant in terms of its role as a potential risk factor for dementia. Several studies find an association between diagnoses of anxiety and depression and subsequent diagnoses of Mild Cognitive Impairment (MCI) and Alzheimer’s (Mortby et al., 2017; Burke et al., 2018; Santabarbara et al., 2019). Some studies found evidence that anxiety, co-existing with MCI, may increase the conversion to dementia (Stella et al., 2014; Mah, Binns and Steffens, 2015; Li and Li, 2018).

Anxiety as a coexisting symptom in early stages of dementia may be impacted by a person’s insight and awareness. Naturally, a person diagnosed with dementia may worry about finances, work, relationships, and health, and how their symptoms may change and progress over time. Increased attentional difficulty (fluctuations in attention) may be a psychological reaction to cognitive losses. A person with dementia may struggle to shift attention between different tasks, and potentially hyperfocus on a single object or task. In the middle or later stages of dementia, anxiety may have some association with their sense of confusion and difficulty understanding their feelings. As dementia progresses it’s likely that an accumulation of cognitive and functional losses leads to a progressive inability to sufficiently manage stress arising from discomfort and daily challenges.

Studies have shown that when comparing people with early onset Alzheimer’s disease (EOAD) and those with late onset Alzheimer’s disease (LOAD) the prevalence of anxiety is significantly worse in those with EOAD (Ballion et al., 2019; Falgàs et al., 2022).

No relationship has been found with age, gender or education (Ballard, 2000; Mendez, 2006). However, anxiety is more common in vascular dementia, frontotemporal dementia and Parkinson’s dementias (Aarsland, 2001).

Anxiety occurring in a person with dementia is often referred to as a ‘behavioural and psychological symptom of dementia’ (BPSD). This term has been discussed in previous articles in the series (Kennedy, 2025a; Kennedy, 2025b). Recently there have been moves to replace the term ‘BPSD’ with a more meaningful term, ‘behavioural expressions of need’ (Marshall et al., 2026). If a person with dementia is exhibiting what some environments refer to as “disruptive” behaviours such as shouting, these can be viewed as the person struggling to express anxiety regarding internal or external difficulties.

Treating anxiety in dementia without medication

Current guidelines from the National Institute for Health and Care Excellence (NICE, 2018b) recommend to first consider psychological interventions for the treatment of people with anxiety and dementia. Various non-pharmacological interventions have been studied including cognitive stimulation (with and without a cholinesterase inhibitor – used for treating Alzheimer’s disease), massage and touch, exercise, reminiscence therapy and occupational therapy. Subsequent meta-analysis (Nimmons et al., 2024) concludes that non-pharmacological interventions are effective in reducing anxiety in people with dementia, particularly highlighting music therapy, cognitive stimulation and exercise.

Treating anxiety in dementia often involves offering reassurance and support. Identification of any obvious environmental triggers (changes to routine, noise, over-stimulation etc) and anticipating unmet needs can prove effective. Dementia affects memory, communication skills, reasoning and problem-solving, and for many this unpredictability can create a feeling of anxiety. For this reason, establishing some sort of routine can provide a sense of security and help reduce some anxiety. If obvious triggers are noted (medical appointments, giving complex and lengthy instructions, going somewhere unfamiliar, etc.) these can be minimised too.

Some lifestyle changes may help, for example, regular physical activity, reducing caffeine and alcohol, and a balanced healthy diet. The role of “talking therapies” may depend on the stage of the person’s dementia and the degree of awareness or insight the person has. GPs can refer their patients to NHS talking therapies, and the British Association of Counselling and Psychotherapy (BACP) can advise on local and suitable services (included in the links). The use of music as a therapy in dementia has gained momentum over recent years and although more research is needed there is growing evidence of its value in the management of anxiety (Bleibel et al., 2023).

When a person with dementia has reached a later stage of the condition, their communication may become increasingly affected which places greater caregiver emphasis on understanding or interpreting the person’s non-verbal communication that indicates anxiety, such as pacing, fidgeting, becoming quickly upset, seeking increased reassurance. Many people with dementia will experience a symptom referred to as “sundowning”. This describes the worsening of neuropsychiatric symptoms in the late afternoon or evening. It is most likely to occur in mid to late-stage dementia affecting roughly 66% of people with dementia (Canevelli et al., 2016). This can manifest as intense confusion, asking / wanting to “go home” and increasing anxiety and restlessness. Strategies to mitigate include establishing routine, reducing day-time naps, keeping the environment calm, avoidance of stimulants and ensuring good lighting.

In some care environments people with dementia may be in later stages of the condition and it can be challenging to offer approaches which are personalised and reduce distress. Doll therapy is a model which fosters the innate sense of attachment to an object. Several systematic reviews have shown doll therapy to reduce anxiety and other forms of distress (Martin-Garcia et al., 2022; Peng et al., 2024), however, it should be introduced with caution. It is valuable to know of a person’s history of attachments as part of life history work beforehand. For many people with dementia this may be introducing a type of “time-shifting”, (reverting to an earlier stage of life) and over-identification (the person believing a doll is their “baby”) is a possibility.

What medications help with anxiety in dementia and what are the main side effects / risks?

In everyday practice psychotropic medications (any medications used for a mental health condition) are used commonly to reduce many symptoms experienced by people with dementia.

As a symptom experienced by people with dementia, anxiety poses challenges to researchers as many studies are “observing” the symptoms, due to those being studied sometimes having reduced ability to self-report.

Antidepressants

Antidepressants are frequently prescribed to help manage anxiety and depression occurring in a person with dementia. In their systematic review, Bingley, Young and Chong (2024) found seven random control trials (RCTs) examining the value of using antidepressants. Although five found them to be of no value, and many of the studies were under-powered (insufficient number of participants), two RCTs found some evidence that antidepressants were effective.

SSRIs are a group of antidepressants commonly used for people with dementia. Their use in relation to depression and dementia is discussed in a previous article in this series (Kennedy 2026). Their mode of action is broadly to increase levels of serotonin in the brain. They are also likely to have an impact on some physiological symptoms of anxiety, such as headaches and muscle tension, whilst a small number help treat insomnia. Notably, most studies look at short-term outcomes. Tricyclic antidepressants have shown similar efficacy to SSRIs, but anticholinergic affects (see glossary) are a concern. Commonly callers to the Admiral Nurse Dementia Helpline are describing the use of specific antidepressants to treat symptoms such as restlessness, irritability and repetitive movements (often referred to by prescribers as “agitation”). Two antidepressants which have been used commonly in treating “agitation” in dementia are mirtazapine and trazadone. Trazadone is reasonably well tolerated but may cause a drop in blood pressure when standing after sitting / lying (orthostatic hypotension) and drowsiness. Its use for “agitation” is off label. Mirtazapine is considered “not clinically effective” for treating agitation in dementia (Banerjee et al., 2021) An important distinction is what symptoms are being treated. If the primary symptoms are anxiety and depression these medications have some utility, but if the goal is clearly one of sedation, associated risks, such as falls, will be a potential concern.

Benzodiazepines

The first benzodiazepine was produced in 1955 (chlordiazepoxide) with diazepam (Valium) following close behind. As a group of medications these are used as hypnotics, anxiolytics, muscle relaxants, anticonvulsants and in alcohol withdrawal (chlordiazepoxide). They are strongly associated with tolerance and dependence. Those with shorter half-lives (see glossary) will often avoid accumulation-type symptoms (such as feeling “hungover”) but be more likely to produce withdrawal symptoms. The use of benzodiazepines in older people can be problematic and is associated with increased falls (Neutal et al., 1996) and hip fracture (Wetterling et al., 2002). Benzodiazepine withdrawal can lead to a type of delirium if the treatment is stopped abruptly.

Benzodiazepine’s primary mode of action is one of enhancing GABA (mentioned earlier) receptors which leads to sedative and relaxant effects. The use of benzodiazepines for anxiety in dementia is a contentious topic. Careful consideration is necessary to balance a person’s perceived benefits of treating versus impact of not treating and risks regarding concordance, abrupt withdrawal and falls. As a rule of thumb, they should be used if necessary for acute anxiety rather than GAD and cautiously, starting at the lowest possible dose and taken for the shortest period.

Cholinesterase inhibitors and memantine

Cholinesterase inhibitors are discussed in the first article in this series (Kennedy 2025a) and are not an effective treatment for anxiety. Memantine has not been specifically examined in relation to anxiety occurring in dementia. The NHS advice for memantine includes reference to helping with symptoms like “being forgetful, feeling confused or feeling anxious” (NHS UK, 2022).

Memantine’s primary value is in late-stage dementia as an augmentation to cholinesterase inhibitors (see Kennedy, 2025a) and it is not licenced specifically to manage anxiety. Pragmatically, however, memory clinics will consider adding memantine to existing cholinesterase inhibitors. The presence of additional symptoms at re-referral such as irritability and anxiety will invariably be considered. As NICE acknowledges in its guide TA217 the purpose of these treatments includes “non-cognitive” symptoms which include hallucinations, delusions and anxiety (NICE, 2018a).

What else exists?

Table 1 briefly outlines other medications which may be used to treat anxiety. This summary is largely drawn from questions posed by callers to the Admiral Nurse Dementia Helpline.

Conclusion

In keeping with the previous three papers in this series this paper is written in response to questions raised in calls to the Admiral Nurse Dementia Helpline on medication issues. Anxiety, a symptom often experienced by people with dementia, poses many challenges, both in its identification and treatment. By providing information in response to common themes, I hope to improve the confidence of anyone involved in caring for or supporting a person with dementia and empower them to ask the right questions of those that prescribe such treatments.

Glossary of terms used

• Anti-cholinergic side effects – blocking the action of acetylcholine (a neurotransmitter crucial for many functions). May include dry mouth, blurred vision, constipation, urinary retention and cognitive impairment.
• Half-life – the time taken for the amount of a medication’s active ingredient to be reduced by half in the human body.
• Prodromal – the period between the appearance of initial symptoms dementia and the full development of the condition.
• Time shifting – a symptom where a person can lose their sense of the present time and may believe they are living in the past.
• Neurotransmitters – chemical messengers that send messages between nerve cells.

References

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Useful links

BACP. Dementia and counselling. Available at: https://www.bacp.co.uk/about-therapy/what-therapy-can-help-with/dementia/