Anxiety Disorders in Later Life

Anxiety disorders occur in about 4% to 10% of community samples of older adults, and anxiety symptoms that do not meet criteria for a disorder affect 15% to 20%.^1-5 Generalized anxiety disorder (GAD), characterized by persistent worry and associated physical symptoms lasting 6 months or longer, is the most common of the pervasive anxiety disorders in later life. Its community prevalence (in all age groups) is estimated to be 4% to 7% and 3% to 11% in older patients in the primary care setting.^6-9 These figures may be significant underestimates, given that many older adults deny psychological problems and emphasize somatic complaints.^10,11

Increased rates of anxiety are typical for older adults with a medical illness, as is higher prevalence among the homebound, nursing home residents, and patients with chronic illness.^12-13Anxiety symptoms are reported in as many as 40% of older patients with disabilities or chronic medical conditions, and poor health outcomes are associated with anxiety, including decreased levels of physical activity, poorer perception of health, memory difficulties, and increased dependence.^14-17 Increased rates of coronary artery disease and mortality are also associated with anxiety.^18-20

Anxiety is also pervasive in older adults with dementia. Symptoms of anxiety occur in 8% to 71% of patients with dementia, and 5% to 21% have a DSM anxiety disorder.²¹ These wide ranges in population estimates result to some degree from differences in population characteristics and measurement strategy, and from lack of clarity about appropriate diagnostic criteria.^21,22 Among patients with dementia, anxiety has been associated with increased behavior problems, poor social functioning, and decreased independence.^23,24 The assessment and treatment of anxiety in patients who have dementia are currently areas of growth and new research.

Older adults can present with anxiety or worries about physical health (illness, changes in vision or hearing), cognitive difficulties, finances, and changes in life status (widowhood, care-giving responsibilities, retirement). Clinicians need to be aware that older adults may deny psychological symptoms of anxiety (fear, worry) but endorse similar emotions with different words (worries, concerns). As noted above, older adults also tend to emphasize somatic rather than psychological symptoms of anxiety.¹¹

Differential diagnosis

Older adults undergo changes in health, ranging from normal aging to chronic medical conditions including hypertension, diabetes, or arthritis. As many as 80% of older adults have at least 1 chronic medical condition.²⁵ Screening tools can be used in medical settings to identify patients who might need further treatment or referrals because of anxiety. The patient health questionnaire PRIME-MD includes a brief screening tool that has demonstrated utility for identifying anxiety and depression in older adults in a medical setting.²⁶

Anxiety is often accompanied by symptoms that mimic physical illness and may include muscle tension or pain, GI symptoms, shortness of breath, and heart palpitations. Older adults with medical conditions might falsely appear to have increased anxiety because they endorse frequent physical symptoms on health questionnaires. Because many assessment instruments are designed to evaluate anxiety in younger adults and include a combination of physiological and psychological symptoms, new measures of anxiety may be needed for older adults. A clear patient history can clarify the relationship between anxiety symptoms and medical conditions. Table 1 lists some self-report instruments that can be used to assess anxiety in older adults.

Depression and anxiety frequently occur together and complicate diagnostic clarity. Late-life anxiety disorders and depression (including major depressive disorder, dysthymia, or
depression not otherwise specified) co-occur at a rate of 15% to 30%.^27,28 Older adults with anxiety and depression use more services, experience reduced quality of life and increased disability, and have more severe somatic symptoms and greater suicidal ideation.^29-31 Key components differentiating depression and anxiety include sequence of symptoms (which came first), the severity of either depression or anxiety, and the prominence of fear or sadness in the clinical presentation. GAD often precedes an episode of depression, which suggests that it may be a risk factor^29,32 Brief measures, such as the Penn State Worry Questionnaire–Abbreviated version can be useful as an efficient screening tool to differentiate worry from depressive rumination.³³

Pharmacological treatment strategies

Older adults receive most of their mental health services from their primary care physicians. Therefore, it is not surprising that in primary care 50% of older patients with anxiety disorders are prescribed anxiolytics or antidepressants and that psychosocial treatments are minimal.³⁴ Only 14% of older adults with anxiety receive services from mental health professionals, including psychiatric medication management or counseling.³⁵ A growing body of research supports evidence-based treatment for late-life anxiety. The literature suggests that both pharmacotherapy and psychosocial interventions can decrease symptoms of anxiety disorders in older adults.³⁶

Benzodiazepines are effective for reducing anxiety in older adults but are generally not recommended for long-term use because of serious adverse effects. Benzodiazepine use can be associated with decreased cognitive functioning, impaired psychomotor performance, and increased risk of falls with resultant hip fracture. Benzodiazepines also can have harmful drug interactions and cause dependence issues. Although caution is recommended when prescribing benzodiazepines, their use in older adults is estimated to be 10% to 12% and as high as 43% in patients with chronic anxiety.³⁴

Antidepressants appear to be effective for the treatment of late-life GAD and other anxiety disorders.³⁴ Clinical trials have demonstrated significant improvements in anxiety, worry, and depressive symptoms for older adults with anxiety disorders following treatment with venlafaxine, citalopram, and sertraline.^36,37

Despite promising results for the use of antidepressants, clinicians should be aware of increased risk factors for older adults, including the potential for drug-drug interactions in medically ill patients. Nonadherence to psychiatric medication is another relevant issue because older adults may forget to take medications, may be confused about dosages, or may overuse prescribed medications. The reasons for nonadherence may include adverse effects, cost considerations, confusion, or insufficient knowledge about proper use.³⁸ Providers may need to offer increased services and collaborate more closely with the patient and family members to monitor and solve issues related to nonadherence.

Antipsychotics are not recommended for the treatment of late-life anxiety.³⁹ The atypical antipsychotics are sometimes prescribed for behavior problems that may be associated with anxiety or psychosis in patients with dementia, but these medications need to be used cautiously in older patients because of increased medication sensitivity, sedation, fluctuation in blood pressure, and increased risk of mortality.⁴⁰

Nonpharmacological treatment strategies

Cognitive-behavioral therapy (CBT) interventions are useful for older adults with anxiety, although support is not as robust as for younger adults.^34,41 Most research in this area has focused on the efficacy of CBT for GAD, although there is also preliminary support for its use in panic disorder and obsessive-compulsive disorder.³⁴ The components of CBT include psychoeducation, self-monitoring, relaxation skills, problem solving, exposure to feared or avoided stimuli, behavioral activation, sleep hygiene, and cognitive restructuring skills.

Case Vignette

Helen is a 73-year-old woman who calls her doctor’s office often. She is frequently concerned about physical symptoms that come and go, and she has many questions about her medications. The nurses in her internist’s office recognize her voice the minute she says hello. When Helen visits her physician, she always has a long list of questions, symptoms, and concerns.

Helen has always been a worrier, but things got much worse after her husband of 40 years died 5 years ago. He had been a significant source of reassurance for her. Once she was alone, she had to find other people to check in with about her worries. Her daughter reports that Helen calls her too often with questions about her health, the grandchildren, and her finances. However, when asked about excessive anxiety or worry by her physician, Helen says, “Oh, no, I don’t worry. I just think too much.”

In addition, Helen does not sleep well; she wakes up often with worries on her mind and cannot get back to sleep. Chronic muscle tension has exacerbated her arthritis, and constant pain has developed in her back and neck. Helen’s daughter also reports that she has been irritable more frequently than in the past, and that her concentration and memory are not as good as they once were.

After a screening evaluation to determine that significant cognitive impairment was not present, Helen’s physician referred her to a therapist in the community who specializes in treating anxiety. At her first visit, the therapist taught Helen how to identify different symptoms of anxiety, although she was careful to use alternative terms that fit with
Helen’s experience of her symptoms (thinking too much, concerns). Helen learned to identify physical tension, worry-related thoughts, and associated behaviors (repetitive telephone calls to check in with her daughter). She recorded her symptoms on simple self-monitoring forms that required only checking boxes and writing brief phrases.

As Helen became more familiar with her anxiety symptoms, she realized what a huge impact they were having on her life and the lives of the people around her. Next, the therapist taught Helen a few simple skills to manage the anxiety. She learned deep breathing, which worked well because it was simple and easily “portable.” Helen also learned how to substitute alternative thoughts when she had concerns about her health, family, or finances, eg, “I just spoke with my daughter this morning; she is okay.” She was able to write some phrases on a note card that she could look at when concerns started to pop into her mind. The therapist also taught Helen better problem-solving skills and ways to face situations that produced anxiety. Over a number of weeks, Helen began to worry less, and she reduced the number of calls she made to her physician and daughter.

A recent review of late-life anxiety treatments found that gains from pharmacotherapy and CBT were equivalent compared with control conditions.³⁶ When conducting CBT with older adults, treatment may need to last longer than the typical 8 to 10 sessions for maximum benefit. Reviews of treatment studies also suggest that individual treatment (rather than group therapy) and behavioral components (rather than cognitive components) are preferable.⁴¹ Individual treatments allow increased flexibility in the learning and application of skills (eg, altering the pace of skills training, simplifying practice exercises and handouts, enlarging fonts on written materials, and varying the time devoted to review learned skills). Treatment may also be improved if CBT includes between- session reminder calls that focus on questions about previous sessions or at-home assignments.⁴²

Anxiety in patients with dementia

The treatment of anxiety in patients with dementia is a new area of study.²¹ To date, all outcome research on late-life anxiety has excluded older adults with cognitive impairment, creating a noticeable gap in understanding how to provide care for this underserved group of patients. Because older adults with cognitive impairments can be at higher risk for the adverse effects of psychiatric medications, psychosocial interventions may be valuable alternatives or adjuncts. Case studies support the use of CBT for anxiety and depression in older adults with dementia.^43-45 However, controlled studies are needed.

Treating patients with dementia requires the clinician to address difficulties with short-term memory, language, and comprehension and retrieval. One strategy to help compensate for difficulties is to use a collateral (such as a spouse or adult child) to act as coach-someone who can also learn the skills and is able to prompt the patient to practice them. Other modifications for treatment of patients with dementia include emphasizing behavioral techniques, exploiting preserved abilities (repetition skills, ability to read aloud, social skills), and using methods to improve comprehension and retrieval. Spaced retrieval is one such learning method that relies on procedural memory and skills to improve encoding.⁴⁶ It may also be important to integrate cognitive testing into treatment with older adults with anxiety to allow treatment adaptations that maximize matching of skills and training procedures with patients’ abilities (Table 2).

Conclusion

Research is beginning to move from academic clinical trials to effectiveness research in nontraditional mental health care settings. Preliminary treatment outcomes of CBT in a primary care setting are promising.^47,48 Telephone sessions may be a way to provide care for older adults who have difficulty with mobility or transportation.⁴⁹ Alternative or complementary treatments such as acupuncture or massage may offer an enhancement to treatments, especially in patients with chronic pain.⁵⁰ Overall, the understanding of late-life anxiety continues to grow; current research focuses on improving the provision of evidence-based treatments to a broad range of older adults.

Disclosures:

The authors report that they have no conflicts of interest concerning the subject matter of this article.

References:

References

1. Bland RC, Newman SC, Orn H. Prevalence of psychiatric disorders in the elderly in Edmonton. Acta Psychiatr Scand Suppl. 1988;338:57-63.
2. Beekman AT, Bremmer MA, Deeg DJ, et al. Anxiety disorders in later life: a report from the Longitudinal Aging Study Amsterdam. Int J Geriatr Psychiatry. 1998;13:717-726.
3. Cohen CI, Magai C, Yaffee R, Walcott-Brown L. The prevalence of anxiety and associated factors in a multiracial sample of older adults. Psychiatr Serv. 2006; 57:1719-1725.
4. Mehta KM, Simonsick EM, Penninx BW, et al. Prevalence and correlates of anxiety symptoms in well-functioning older adults: findings from the health aging and body composition study. J Am Geriatr Soc. 2003;51:499-504.
5. Wittchen HU, Kessler RC, Beesdo K, et al. Generalized anxiety and depression in primary care: prevalence, recognition, and management. J Clin Psychiatry. 2002;63(suppl 8):24-34.
6. Kessler RC, Wittchen HU. Patterns and correlates of generalized anxiety disorder in community samples. J Clin Psychiatry. 2002;63(suppl 8):4-10.
7. Roy-Byrne PP, Wagner A. Primary care perspectives on generalized anxiety disorder. J Clin Psychiatry. 2004;65(suppl 13):20-26.
8. Ansseau M, Dierick M, Butinkx F, et al. High prevalence of mental disorders in primary care. J Affect Disord. 2004;78:49-55.
9. Tolin DF, Robison JT, Gaztambide S, Blank K. Anxiety disorders in older Puerto Rican primary care patients. Am J Geriatr Psychiatry. 2005;13:150-156.
10. Kogan JN, Edelstein BA, McKee DR. Assessment of anxiety in older adults: current status. J Anxiety Disord. 2000;14:109-132.
11. Lenze EJ, Karp JF, Mulsant BH, et al. Somatic symptoms in late-life anxiety: treatment issues. J Geriatr Psychiatry Neurol. 2005;18:89-96.
12. Bruce ML, McNamara R. Psychiatric status among the homebound elderly: an epidemiologic perspective. J Am Geriatr Soc. 1992;40:561-566.
13. Junginger J, Phelan E, Cherry K, Levy J. Prevalence of psychopathology in elderly persons in nursing homes and in the community. Hosp Community Psychiatry. 1993;44:381-383.
14. Brenes GA, Guralnik JM, Williamson JD, et al. The influence of anxiety on the progression of disability. J Am Geriatr Soc. 2005;53:34-39.
15. Kunik ME, Roundy K, Veazey C, et al. Surprisingly high prevalence of anxiety and depression in chronic breathing disorders. Chest. 2005;127:1205-1211.
16. Lenze EJ, Rogers JC, Martire LM, et al. The association of late-life depression and anxiety with physical disability: review of the literature and prospectus for future research. Am J Geriatr Psychiatry. 2001; 9:113-135.
17. Naik AD, Concato J, Gill TM. Bathing disability in community-living older persons: common, consequential, and complex. J Am Geriatr Soc. 2004;52: 1805-1810.
18. Brenes GA, Kritchevsky SB, Mehta KM, et al. Scared to death: results from the Health, Aging, and Body Composition study. Am J Geriatr Psychiatry. 2007;15:262-265.
19. Kawachi I, Sparrow D, Vokonas PS, Weiss ST. Symptoms of anxiety and risk of coronary heart disease. The Normative Aging Study. Circulation. 1994; 90:2225-2229.
20. van Hout HP, Beekman AT, de Beurs E, et al. Anxiety and the risk of death in older men and women. Br J Psychiatry. 2004;185:399-404.
21. Seignourel PJ, Kunik ME, Snow L, et al. Anxiety in dementia: a critical review. Clin Psychol Rev. 2008 Mar 7. [Epub ahead of print].
22. Starkstein SE, Jorge R, Petracca G, Robinson RG. The construct of generalized anxiety disorder in Alzheimer disease. Am J Geriatr Psychiatry. 2007;15:42-49.
23. 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;15:180-186.
24. Schultz SK, Hoth A, Buckwalter K. Anxiety and impaired social function in the elderly. Ann Clin Psychiatry. 2004;16:47-51.
25. Cully JA, Stanley MA. Assessment and treatment of anxiety in later life. In: Laidlaw K, Knight B, eds. Handbook of Emotional Disorders in Later Life: Assessment and Treatment. New York: Oxford University Press; 2008:233-256.
26. Kunik ME, Azzam PN, Souchek J, et al. A practical screening tool for anxiety and depression in patients with chronic breathing disorders. Psychosomatics. 2007;48:16-21.
27. Beekman AT, de Beurs E, van Balkom AJ, et al. Anxiety and depression in later life: co-occurrence and communality of risk factors. Am J Psychiatry. 2000;157:89-95.
28. van Balkom AJ, Beekman AT, de Beurs E, et al. Comorbidity of the anxiety disorders in a community-based older population in The Netherlands. Acta Psychiatr Scand. 2000;101:37-45.
29. Lenze EJ, Mulsant BH, Shear MK, et al. Anxiety symptoms in elderly patients with depression: what is the best approach to treatment? Drugs Aging. 2002; 19:753-760.
30. Schoevers RA, Beekman AT, Deeg DJ, et al. Comorbidity and risk-patterns of depression, generalized anxiety disorder and mixed anxiety-depression in later life: results from the AMSTEL study. Int J Geriatr Psychiatry. 2003;18:994-1001.
31. Steffens DC, McQuoid DR. Impact of symptoms of generalized anxiety disorder on the course of late-life depression. Am J Geriatr Psychiatry. 2005;13:40-47.
32. Wetherell JL, Gatz M, Pedersen NL. A longitudinal analysis of anxiety and depressive symptoms. Psychol Aging. 2001;16:187-195.
33. Webb SA, Diefenbach G, Novy DM, et al. Comparison of self-report measures for identifying late-life generalized anxiety in primary care. J Geriatr Psychiatry Neurol. 2008. In press.
34. Wetherell JL, Lenze EJ, Stanley MA. Evidence-based treatment of geriatric anxiety disorders. Psychiatr Clin North Am. 2005;28:871-896.
35. Schuurmans J, Comijs HC, Beekman AT, et al. The outcome of anxiety disorders in older people at 6-year follow-up: results from the Longitudinal Aging Study Amsterdam [comment]. Acta Psychiatr Scand. 2005; 111:401-402.
36. Pinquart M, Duberstein PR. Treatment of anxiety disorders in older adults: a meta-analytic comparison of behavioral and pharmacological interventions. Am J Geriatr Psychiatry. 2007;15:639-651.
37. Schuurmans J, Comijs H, Emmelkamp PM, et al. A randomized, controlled trial of the effectiveness of cognitive-behavioral therapy and sertraline versus a waitlist control group for anxiety disorders in older adults. Am J Geriatr Psychiatry. 2006;14:255-263.
38. Mental Health: A Report of the Surgeon General. US Department of Health and Human Services. Washington, DC: National Institute of Health; 1999.
39. Alexopoulos GS, Streim J, Carpenter D, et al. Using antipsychotic agents in older patients. J Clin Psychiatry. 2004;65(suppl 2):5-99.
40. Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA. 2005;294:1934-1943.
41. Ayers CR, Sorrell JT, Thorp SR, Wetherell JL. Evidence-based psychological treatments for late-life anxiety. Psychol Aging. 2007;22:8-17.
42. Mohlman J, Gorenstein EE, Kleber M, et al. Standard and enhanced cognitive-behavior therapy for late-life generalized anxiety disorder: two pilot investigations. Am J Geriatr Psychiatry. 2003;11:24-32.
43. Koder DA. Treatment of anxiety in the cognitively impaired elderly: can cognitive-behavior therapy help? Int Psychogeriatr. 1998;10:173-182.
44. Kraus CA, Seignourel P, Balasubramanyam V, et al. Cognitive behavioral treatment for anxiety in patients with dementia: two case studies. J Psychiatr Pract. 2008;14:186-192.
45. Teri L, Gallagher-Thompson D. Cognitive-behavioral interventions for treatment of depression in Alzheimer’s patients. Gerontologist. 1991;31:413-416.
46. Camp CJ. Facilitation of new learning in Alzheimer’s disease. In: Gilmore GC, Whitehouse PJ, Wykle ML, eds. Memory, Aging, and Dementia: Theory, Assessment, and Treatment. New York: Springer; 1989: 212-225.
47. Stanley MA, Hopko DR, Diefenbach GJ, et al. Cognitive-behavior therapy for late-life generalized anxiety disorder in primary care: preliminary findings. Am J Geriatr Psychiatry. 2003;11:92-96.
48. Stanley MA, Novy DM, Kunik ME, et al. Preliminary outcomes: late-life GAD in primary care. Presented at: Association for the Advancement of Behavior Therapy; November 2005; Washington, DC.
49. Brenes GA, McCall WV, Williamson JD, Stanley MA. Feasibility and acceptability of bibliotherapy and telephone sessions for the treatment of late life anxiety disorders. Clin Gerontol. 2008. In press.
50. Meeks TW, Wetherell JL, Irwin MR, et al. Complementary and alternative treatments for late-life depression, anxiety, and sleep disturbances: a review of randomized controlled trails. J Clin Psychiatry. 2007; 68:1461-1471.
51. Wisocki PA, Handen B, Morse CK. The Worry Scale as a measure of anxiety among homebound and community active elderly. Behav Therapist. 1986;5:91-95.
52. Pachana NA, Byrne GJ, Siddle H, et al. Development and validation of the Geriatric Anxiety Inventory. Int Psychogeriatr. 2007;19:103-114.
53. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol. 1988;56:893-897.
54. Lovibond PF, Lovibond SH. The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther. 1995; 33:335-343.
55. Antony MM, Bieling PJ, Cox BJ, et al. Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample. Psychol Assess. 1998;10:176-181.
56. Spielberger CD, Gorsuch RL. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press; 1970.
57. Meyer TJ, Miller ML, Metzger RL, Borkovec TD. Development and validation of the Penn State Worry Questionnaire. Behav Res Ther. 1990;28:487-495.
58. Hopko DR, Stanley MA, Reas DL, et al. Assessing worry in older adults: confirmatory factor analysis of the Penn State Worry Questionnaire and psychometric properties of an abbreviated model. Psychol Assess. 2003;15:173-183.