Older adults suffer from the entire range of anxiety disorders. The clinician treating older persons therefore needs to be familiar with the hallmarks and available treatments for each type of anxiety disorder. Since the published literature on anxiety in elderly patients is relatively sparse, some of the characterizations and treatment strategies described here are based on research carried out in younger populations. They have been modified to take into account the physiologic and psychologic differences between older and younger adults.
Familiarity with the various diagnostic criteria, along with the skill to conduct a thorough psychologic assessment, is crucial in determining the most appropriate treatment for anxiety. Clinicians need to be aware of difficulties in proper assessment of geriatric anxiety; these include medical comorbidity, the difficulty of differentiating anxiety from depression, falsely high scores on anxiety rating scales resulting from overemphasis of cardiac and respiratory problems, and the tendency of older patients to resist psychiatric evaluation.
Anxiety assessment begins with a clinical interview to determine the course and nature of symptoms, along with the nature of the patient’s mental status and external support. Supplemental rating scales, which aid in comparing a patient’s level of difficulties with that of others and assessing difficulties over time, along with laboratory investigations, can result in an accurate clinical picture and the ability to formulate an effective management plan. Even though discrete anxiety disorders such as panic disorders are less prevalent among older than among younger adults, anxiety as a symptom is a common problem. The ability to recognize and effectively treat anxiety in older persons is important, given the debilitating effects that an unhealthy level of anxiety can have in this vulnerable population.
The types of anxiety disorders as currently defined in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) are listed in Table 36.1.
Panic attacks are acute, discrete episodes of intense anxiety that result as a reaction to some perceived threat (eg, emotional, environmental). The term panic attack is used when a person experiences an intense and acute reaction to an internal or external cue; it lasts between a few minutes and a half hour. The physiologic symptoms may include trembling, accelerated heart rate, sweating, shortness of breath, chest pain, dizziness, nausea, and the sense that one is somehow detached from the surroundings. For example, a person might have a fear of being trapped on an elevator and report feeling dizzy and nauseated when entering one. Another might report high levels of acute anxiety at the mere sight of elevator doors. A clinically significant degree of panic symptoms exists if a review of the patient’s history reveals that recurrent and unpredictable panic attacks have occurred for at least 1 month and time is being spent in worried anticipation of possible reoccurrence. Diagnostically, one needs also to consider whether agoraphobia related to the panic attacks is present. In such cases, agoraphobia involves the persistent fear of situations that result in a panic attack, as when a patient reports remaining at home in order to avoid an attack. Common examples of feared situations include being caught in a crowd or trapped in traffic. Comparison of young and older adults with panic disorder indicates that age of onset can affect the clinical presentation. Patients with late-onset panic disorder (at or after age 55) report fewer panic symptoms and less avoidance, and they score lower on somatization measures than do those with early-onset panic disorder. Also, earlier-onset panic more commonly persists into old age.
Phobias include several distinct disorders, categorized as specific phobia and social phobia. A specific phobia involves a distinct trigger, such as a specific person, animal, place, object, event, or situation that results in symptoms of anxiety. Commonly, the patient’s anxiety level increases instantly when the feared trigger is encountered. Interestingly, he or she is able to identify this fear as unrealistic and unsupported, even though the cognitive and physiologic responses persist. Specific phobias often involve a great amount of anticipatory anxiety (thoughts of just the possibility of encountering the feared stimulus), and avoidance behaviors are likely to be reported. The consequence of such a clinical profile is that the person experiences a variety of personal difficulties as a result of the anxiety. These behaviors interfere with work and daily routines, and they decrease the person’s opportunities to experience pleasurable situations (for fear that a trigger might be present). They may also contribute to secondary symptoms, such as frustration, hopelessness, and a sense that one lacks control in one’s life. The level of anxiety or fear usually varies as a function of both the degree of proximity to the phobic stimuli and the degree to which escape is limited. Examples of common phobias include fear of specific animals, closed spaces, flying, or heights. Frequently, specific phobias occur with panic disorder, with or without agoraphobia. Among elderly persons, especially in urban settings, fear of crime seems to be particularly prevalent. Phobic disorders tend to be chronic and persist into old age. However, fear of falling is a specific phobia that is increasingly recognized to have an onset in later life.
Persons with social phobia suffer from fears that they will behave in a manner that is inept or embarrassing. Commonly, the fear is that of trembling, blushing, or sweating profusely in social situations. Other common feared situations involve giving public speeches, going on dates, or simply socializing with others at a function or party. Again, as with specific phobias, social phobia is often accompanied with a significant degree of anticipatory anxiety or avoidance, or both. Though systematic studies of this disorder in elderly persons are lacking, epidemiologic data indicate that this disorder is chronic and persistent in old age. Common manifestations in old age include the inability to eat food in the presence of strangers, and, especially in men, being unable to urinate in public lavatories.
Obsessive-compulsive disorder involves persistent thoughts (obsessions) and behaviors (compulsions) that are performed in an effort to decrease the anxiety experienced as a result of the thoughts. Obsessions are thoughts or ideas that come to a person’s mind, commonly while completing a specific task or during a particular type of situation. For example, a person may wash his hands repeatedly, for hours at a time, after shaking a stranger’s hand; the unwanted thought is that he may have exposed himself to a serious disease. The act of washing in this example is the compulsion. Obsessive-compulsive disorder is chronic and often disabling. Depression and other symptoms of anxiety may also be comorbid in an older population. A new occurrence of obsessive-compulsive disorder in late life is unlikely. More commonly, symptoms of obsessions occur along with a depressive syndrome or early dementia. For example, obsessions about paying bills on time may occur in the context of difficulty in estimating time and planning.
The distinctive feature of posttraumatic stress disorder is that the person has experienced, either as a witness or a victim, a traumatic event to which he or she has reacted with feelings of fear and helplessness. Examples of such events include those that involve actual or threatened death or serious injury, other threats to one’s integrity, witnessing an event that involves death or serious injury of another, or even hearing about death or serious injury to a family member or close associate. Commonly observed symptoms include the re-experiencing of the traumatic event, avoidance (both cognitively and behaviorally) of stimuli associated with the event, psychologic numbing, and increased physiologic arousal. Symptoms of hyperarousal include difficulty falling or staying asleep, hypervigilance, and exaggerated startle response. Disorders often found to occur with posttraumatic stress disorder include depression, panic disorder, and substance-use disorders. Symptoms must be present for at least 1 month and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. In the short term, that is, between 2 days and 1 month after the traumatic event, a diagnosis of acute stress disorder is given; thereafter, one must consider a diagnosis of posttraumatic stress disorder.
The distinctive symptoms of generalized anxiety disorder include feeling easily tired and experiencing other physical symptoms, such as muscle tension, having trouble sleeping through the night, difficulty concentrating on a task, and feeling irritable or on edge. These symptoms need to have occurred for at least 6 months and must be accompanied by the sense that one cannot control the feelings of anxiety. In addition, these feelings of intense worry must be a result of more than one stressor. For example, intense worry over financial matters or a medical illness alone, even with all the associated symptoms, in and of itself does not qualify a person for a diagnosis of generalized anxiety disorder. Because many elderly patients with this disorder also present with features of depression, the clinician may try to distinguish between the two diagnoses. Commonly the overlap is sufficiently extensive to preclude this distinction, as described below.
Mixed anxiety and depression is a presentation that is included in the DSM-IV “Criteria for Further Study.” The essential features of this proposed disorder are dysphoric mood for at least 1 month that is composed of at least four anxious or depressive symptoms, such as irritability, worry, sleep disturbance, anticipating the worst, concentration or memory difficulties, and hopelessness. Clinicians working with elderly persons have long observed the significant overlap in symptoms of anxiety and depression. In fact, it is quite common to see individuals with a combination of anxiety and depression, although one or both disorders might be present only at subsyndromal levels.
Patients with dementia, whether living at home or in a long-term-care institution, commonly display behaviors described as agitation. Agitation takes the form of verbal or motor activity that is either appropriate behavior but repeated frequently or inappropriate behavior that suggests lack of judgment. As many as 85% of dementia patients eventually develop disruptive, agitated behavior. Early identification of triggers, including environmental stimuli, medication side effects, and uncommunicated internal needs, can result in effective treatment and relief for already overburdened caregivers. See Dementia and Behavioral Problems in Dementia for details on diagnosing and managing disruptive, agitated behavior.
It is common to encounter patients with comorbid anxiety and medical disorders. This could be due to longstanding anxiety disorder that coincidentally occurs alongside a medical illness, or there could be interplay between the two. There are conditions exacerbated by anxiety, such as the common cold or influenza, and also those that are precipitated by high levels of anxiety, such as angina pectoris or myocardial infarction. Other medical illnesses that commonly accompany an anxiety disorder include cardiovascular illnesses, pulmonary disorders, drug side effects (eg, thyroid hormone replacements, antipsychotics, caffeine, theophylline, selective serotonin-reuptake inhibitors [SSRIs]) or interactions, and hyperthyroidism. Given the complicated clinical picture that results when anxiety and medical disorders coexist, a thorough assessment, including a clinical history, is imperative before treatment begins.
Numerous compounds have been used over the years as anxiolytics: alcohol, barbiturates, antihistamines, benzodiazepines, antipsychotic medications, and β-blockers. Although empirical studies of the use of anxiolytics in treating elderly persons are lacking, the efficacy of these medications is inferred from clinical practice with younger patients, and their use is modified by age-appropriate dosing. A brief description of the various classes of compounds currently favored as anxiolytics follows. Table 36.2 summarizes the treatment strategies for anxiety disorders in late life.
Antidepressants are efficacious in the treatment of panic disorder, obsessive-compulsive disorder, generalized anxiety disorder, and posttraumatic stress disorder in younger patients. Given their relatively favorable side-effect profile, the SSRIs or serotonin–norepinephrine reuptake inhibitors (eg, venlafaxine) should now be considered the drugs of choice for these disorders. Further, SSRIs should also be considered treatments of choice for treating mixed anxiety and depression. Compounds such as venlafaxine should be considered as alternatives for those patients who do not respond to SSRIs or who develop adverse effects. Case reports, open-label trials, and, more recently, controlled trials of serotonergic antidepressants like trazodone and SSRIs have also suggested a modest degree of efficacy in the management of anxiety and agitation in dementia, particularly when patients are not psychotic and comorbid depression is a strong possibility. (See also Behavioral Problems in Dementia.)
Over the past several decades benzodiazepines have been the most commonly prescribed anxiolytics for both young and older patients, but their use is now discouraged. When needed because symptoms are severe, benzodiazepines with a short half-life, such as lorazepam and oxazepam, are preferable in treating elderly patients because they are metabolized by direct conjugation, a process relatively unaffected by aging. However, it is preferable to limit the use of even short-acting benzodiazepines to less than 6 months because long-term use is fraught with multiple complications, such as motor incoordination and falls, cognitive impairment, depression, and the potential for abuse and dependence.
Several studies have suggested that buspirone, an anxiolytic medication with some serotonin-agonist properties, is efficacious in the treatment of patients with generalized anxiety disorder, although clinical experience is less positive. Buspirone appears to be a safer choice than benzodiazepines for patients taking several other medications or needing to be treated for longer periods of time. One drawback of buspirone is the amount of time required to see a clinical response (approximately 4 weeks). This suggests that concomitant use of a short-acting benzodiazepine in the initial stage of treatment would be useful for some patients. Buspirone may also be efficacious in reducing symptoms of anxiety and agitation in patients with dementia. Antihistamines such as hydroxyzine and diphenhydramineOL are sometimes used to manage mild anxiety, but there are few data that demonstrate efficacy and the anticholinergic properties of these agents can cause serious problems. Finally, atypical antipsychotics, such as risperidoneOL, olanzapineOL, and quetiapineOL, are increasingly being used to manage anxiety and agitation associated with dementia, particularly when an underlying psychosis may be present.
Although pharmacotherapy is commonly the first-line treatment for late-life anxiety disorders, psychologic treatments are often adequate, either alone or as adjuncts to medication. Techniques generally fall into three categories. Relaxation training can be employed with the use of music, visual imagery, aromatherapy, or instruction in relaxation techniques. Cognitive restructuring helps the patient identify triggers and stimuli that maintain anxiety and helps him or her to slowly gain more control over the effect of such stimuli and develop a range of coping strategies and tools. Finally, exposure, with response prevention, has been shown to be particularly effective with both panic disorder and obsessive-compulsive disorder. Treatment of the elderly person typically includes a combination of these behavioral approaches. Their success depends on the appropriateness of the patient for psychotherapy; the patient’s support system, intellectual functioning, and motivation level; the degree of coordination of care with medical professionals; and the nature of the disorder. Consultation with a mental health professional can assist in determining the appropriateness of a referral.
■ De Beurs E, Beekman AT, Deeg DJ, et al. Predictors of change in anxiety symptoms of older persons: results from the Longitudinal Aging Study Amsterdam. Psychol Med. 2000;30(3):515–527.
This study reviews the clinical course of anxiety over time through comparison of two groups of older adults residing in the community, those suffering from anxiety and those without symptoms. Risks factors were assessed and included vulnerability factors, such as demographics and social support, and stressors, including those life events that occurred during participation in the study. Those who were found to be most likely to become anxious were slightly neurotic females who suffer from a sensory deficit (eg, hearing or eyesight problems) and experienced a stressful life event during the course of the study. These results will aid in targeting at-risk individuals for preventive care.
■ Kogan JN, Edelstein BA, McKee DR. Assessment of anxiety in older adults. J Anxiety Disord. 2000; 14(2):109–132.
About 25% of older adults meet criteria for some mental disorder. Of this group, anxiety is the most commonly reported diagnosis. This reality necessitates the understanding of anxiety in the elderly age group, including the prevalence rates for each disorder, clinical presentations, outcomes, and the important role of assessment in each of these factors. This article reviews each of these areas and presents recommendations for assessment and future research.
■ Mostofsky DI, Barlow DH, eds. The Management of Stress and Anxiety in Medical Disorders. Needham Heights, MA: Allyn & Bacon; 2000.
This book includes a collection of chapters addressing anxiety associated with various medical conditions. Psychologic components and interventions, including cognitive-behavioral therapy and biofeedback, are reviewed. The various manifestations of anxiety, including insomnia and chronic fatigue syndrome, are discussed in light of current treatment developments. The specific issues associated with geriatric patients’ suffering from anxiety, such as polypharmacy and comorbid medical conditions, are included to assist clinicians in identifying these factors early in treatment.
■ Sheikh JI. Anxiety in older adults: assessment and management of three common presentations. Geriatrics. 2003;58(5):44–45.
This report discusses the three most common presentations of anxiety in older adults seen in primary care: mixed anxiety-depression, anxiety associated with illness or medications, and anxiety or agitation associated with dementia. Symptom profiles and clinical considerations are given for each condition. Pharmacologic treatment strategies are proposed.
Erin L. Cassidy, PhD
Javaid I. Sheikh, MD