How anxiety presents differently in older adults

Current Psychiatry

Vol. 10, No. 3

lthough anxiety disorders are common at all

ages, there is a misconception that their preva-

lence drastically declines with age. For this rea-

son anxiety disorders often are underdiagnosed and

undertreated in geriatric patients, especially when the

clinical presentation of these disorders in older patients

differs from that seen in younger adults.

In older persons, anxiety symptoms often overlap

with medical conditions such as hyperthyroidism and

geriatric patients tend to express anxiety symptoms as

medical or somatic problems such as pain rather than

as psychological distress.

As a result, older adults of-

ten seek treatment for depressive or anxiety symptoms

from their primary care physician instead of a psychia-

trist. Unfortunately, primary care physicians often miss

psychiatric illness, including anxiety disorders, in geri-

atric patients.

Anxiety may be a symptom of an underlying psychi-

atric disturbance, secondary to a general medical con-

dition, or induced by dietary substances, substances of

abuse, or medications. Late-life anxiety often is comor-

bid with major depressive disorder (MDD) (Box, page

66) and other psychological stressors as older adults

recognize declining cognitive and physical functioning.

Anxiety disorders commonly begin in early adulthood,

tend to be chronic and interspersed with remissions and

relapses, and usually continue into old age.

In generalized

anxiety disorder (GAD), there is a bimodal distribution of

onset; approximately two-thirds of patients experience

onset between the late teens and late 20s and one-third de-

velop the disorder for the rst time after age 50.

Age-related changes,

medical comorbidities alter

presentation and treatment

How anxiety presents dierently

in older adults

Nazem Bassil, MD

Assistant Professor of Medicine/Geriatrics

Faculty of Medicine

Balamand University

St. George Hospital Medical Center

Beirut, Lebanon

Abdalraouf Ghandour, MD

Fellow

Division of Geriatric Medicine

University of Missouri, Columbia

Columbia, MO

George T. Grossberg, MD

Samuel W. Fordyce Professor

Director of Geriatric Psychiatry

Department of Neurology and Psychiatry

St. Louis University School of Medicine

St. Louis, MO

continued

Current Psychiatry

March 2011

Anxiety in

older adults

Prevalence rates for anxiety disorders

among older adults (age ≥55) range from

3.5% to 10.2%.

These rates are slightly low-

er than those for younger adults.

Among

older adults, presence of a 12-month anxi-

ety disorder was associated with female

sex, lower education, being unmarried,

and having ≥3 or more chronic conditions.

Anxiety and disability risk

Anxiety disorders affect geriatric patients

more profoundly than their younger coun-

terparts. Persons age >65 who have an

anxiety disorder are 3 to 10 times more

likely to be hospitalized than younger in-

dividuals.

Anxiety is associated with high

rates of medically unexplained symptoms,

increased use of health care resources,

chronic medical illness, low levels of phys-

ical health-related quality of life, and phys-

ical disability.

7,8

Anxiety symptoms may predict pro-

gressing physical disability among older

women and reduced ability to perform ac-

tivities of daily living over 1 year.

Anxious

geriatric patients are less independent and

increase the burden on family and caregiv-

ers.

Anxiety disorders are associated with

lower compliance with medical treatment,

which could worsen chronic medical con-

ditions and increase the risk for nursing

home admission.

Anxious older adults

report decreased life satisfaction, memo-

ry impairment, poorer self perception of

health, and increased loneliness.

Generalized anxiety disorder

Although GAD is the most common anxi-

ety disorder among geriatric patients, with

a prevalence of 0.7% to 9%,

it remains

underdiagnosed and undertreated.

In a

cross-sectional observational study of 439

adults age ≥55 with lifetime GAD, approxi-

mately one-half experienced onset after

age 50.

Late onset is associated with more

frequent hypertension and a poorer health-

related quality of life than early onset.

Compared with younger individuals,

older persons with GAD have a greater

variety of worry topics, including memory

loss,

medical illnesses, and fear of falls,

but worry less about the future and work

than younger patients. This type of anxi-

ety is largely situational and temporary,

and often accompanies comorbid medical

problems (Table 1).

Obsessive-compulsive disorder

A study comparing older (age ≥60) and

younger obsessive-compulsive disorder

(OCD) patients found that the clinical pre-

sentation of the disorder does not substan-

tially differ between age groups; however,

geriatric patients had fewer concerns about

symmetry, needing to know, and counting

rituals. Handwashing and fear of having

sinned were more common.

OCD is fairly uncommon in geriatric

patients. Prevalence rates decrease with

age, ranging between 0% and 0.8% among

persons age ≥60.

OCD seldom begins in

Clinical Point

Handwashing and

fear of having sinned

are more common in

older OCD patients

than in younger ones

he Longitudinal Aging Study Amsterdam

study—one of the largest epidemiologic

studies to examine comorbidity of anxiety

disorders and depression in patients age 55

to 85—found that 48% of older persons with

primary major depressive disorder (MDD) also

had a comorbid anxiety disorder, whereas

approximately one-fourth of those with anxiety

disorders also had MDD.

Pre-existing anxiety

disorders, such as social phobia, obsessive-

compulsive disorder, specific phobia,

agoraphobia, and panic disorder, increase

the risk of developing depression.

Rates of

comorbid anxiety and depression increase

with age.

Late-life MDD comorbid with generalized

anxiety disorder or panic disorder is associated

with greater memory decline than MDD alone.

In addition, comorbid anxiety and depression

is associated with greater symptom severity

and persistence, greater functional impairment,

substance dependence, poorer compliance and

response to treatment, worse overall prognosis

and outcome than patients with either disorder

alone,

and greater likelihood of suicidal ideation

in older men.

Comorbid anxiety and depression: Highly prevalent, poorer outcomes

Box

Source: For reference citations, see this article at CurrentPsychiatry.com

Current Psychiatry

Vol. 10, No. 3

late life; most geriatric patients with OCD

have had symptoms for decades. By late

life, most individuals with OCD improve,

although they may continue to experience

clinical or subclinical symptoms.

How-

ever, 1 report found a second peak of in-

cidence of OCD in women age ≥65.

Case

reports of late-onset OCD have found evi-

dence of cerebral lesions, often in the basal

ganglia, which suggests a possible neuro-

degenerative pathophysiology.

Posttraumatic stress disorder

Untreated posttraumatic stress disorder

(PTSD) often is assumed to be a chronic

disorder. Recollections of past trauma

may lead to new PTSD symptoms in older

patients. Neurodegeneration of memory

pathways and cognitive impairment as-

sociated with Alzheimer’s disease or vas-

cular or alcohol-related dementia may

disinhibit PTSD symptoms in patients

whose PTSD was fairly well controlled.

Life events associated with aging—death

of a spouse, nancial and physical decline,

chronic pain, or diminished cognitive cop-

ing resources—may precipitate or revive

PTSD symptoms associated with earlier

exposure to severe psychological trauma.

These life changes also may precipitate so-

called delayed PTSD, when symptoms re-

lating to past traumatic experiences present

for the rst time. Geriatric patients may be

more likely than younger persons to deny

their PTSD symptoms if their cultural back-

ground emphasizes stoicism and fortitude.

Phobias

Specic phobias. The prevalence of spe-

cic phobias drops dramatically in late life,

although older patients might underreport

symptoms. Many older persons are afraid

of falling. Approximately 60% of older

adults with a history of falling—and 30%

of older individuals with no such history—

report this fear. Fear of falling is more prev-

alent in women and increases with age.

25,26

This fear may be a protective response to a

real threat that prevents older persons from

attempting high-risk activities, but it also

can cause patients to restrict their activities,

which can result in decreased social, physi-

cal, or cognitive functioning and loss of in-

dependence.

Social phobias (social anxiety disorder).

Among older adults, common social pho-

bias include eating food around strangers,

and—especially in men—being unable to

urinate in public bathrooms. In a cross-

Clinical Point

Life changes may

precipitate so-called

delayed PTSD, when

symptoms relating

to past traumatic

experiences present

for the rst time

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6

months, about a number of events or activities (such as work or school performance)

B. The person finds it difficult to control the worry

C. The anxiety and worry are associated with 3 or more of the following symptoms with at least some

symptoms present for more days than not for the past 6 months:

1. Restlessness or feeling keyed up or on edge

2. Being easily fatigued

3. Difficulty concentrating or mind going blank

4. Irritability

5. Muscle tension

6. Sleep disturbance

D. The focus of the anxiety and worry is not confined to features of an axis I disorder

E. The symptoms cause clinically significant distress or impairment in social, occupational, or other

important areas of functioning

F. The disturbance is not due to the direct physiological effects of a substance or a general medical

condition and does not occur exclusively during a mood disorder, a psychotic disorder, or a

pervasive developmental disorder

Source: Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric

Association; 2000

DSM-IV-TR criteria for generalized anxiety disorder

Table 1

Current Psychiatry

March 2011

Anxiety in

older adults

sectional observational study, social anxi-

ety disorder (SAD) was more common

among older persons who reported stress-

ful life events, such as death of a spouse.

MDD, specic phobia, and personality dis-

order are associated with SAD in geriatric

patients.

Prevalence rates of SAD appear

to slightly decrease with age, although the

condition remains common in geriatric pa-

tients—5% of older adults report lifetime

prevalence—and its presentation is similar

to that seen in younger adults.

Agoraphobia. In older persons the preva-

lence of agoraphobia is 0.6%.

Most cases

are of early onset but the condition can

present de novo following a stroke or oth-

er medical event and can inhibit activities

needed for successful rehabilitation. Ago-

raphobia can present within the context of

panic attacks as is seen in younger adults

but most geriatric patients with agorapho-

bia do not have concurrent panic disorder.

This phobia is more common in women,

widowed or divorced individuals, patients

with chronic health conditions, and those

with comorbid psychiatric disorders.

Panic disorder

Panic disorder (PD) rarely starts for the

rst time after age 60, and most late-onset

panic attacks are associated with medi-

cal and psychiatric comorbidities. PD

tends to be less severe in older individu-

als than in younger adults.

Recent stress-

ful life events or losses can predict onset

and maintenance of PD. Older patients

may present with panic symptoms, such

as shortness of breath, dizziness, or trem-

bling, that overlap with age-related medi-

cal conditions. PD may be prevalent in

older patients with chest pain and no evi-

dence of coronary artery disease.

Panic

symptoms that are secondary to underly-

ing medical conditions, such as chronic ob-

structive pulmonary disease exacerbation,

usually wax and wane.

Treatment

Treatment for anxiety disorders in geri-

atric patients may involve a combination

of psychotherapy, pharmacotherapy, and

complementary and alternative therapies.

Treatment may be complicated if patients

have >1 anxiety disorder or suffer from

comorbid depression, substance abuse, or

medical problems. As is seen with younger

adults, the course of anxiety disorders in

older patients waxes and wanes, but most

disorders are unlikely to remit completely.

Aging may inuence the effects of psy-

chotropic medications in older patients.

Increased distribution and decreased me-

tabolism and clearance of medications re-

sults in higher medication plasma levels

and longer elimination half-lives. Medica-

tion compliance in older patients may be

complicated by:

• older patients’ sensitivity to anticho-

linergic side effects

• coexisting medical illnesses

• polypharmacy, particularly in institu-

tionalized settings

• sensory and cognitive decits.

Clinical Point

Older patients may

present with panic

symptoms, such as

shortness of breath,

dizziness, or trembling,

that overlap with

medical conditions

Medication Comments

Selective serotonin reuptake

inhibitors

May be useful for GAD, panic disorder, OCD, and PTSD

Serotonin-norepinephrine

reuptake inhibitors

May be useful for GAD, panic disorder, OCD, and PTSD

Tricyclic antidepressants Potential for cardiotoxicity and overdose, anticholinergic properties

Benzodiazepines Chronic use can lead to cognitive impairment, falls

Buspirone Effective for GAD, but not panic disorder; may take 2 to 4 weeks

to be effective

GAD: generalized anxiety disorder; OCD: obsessive-compulsive disorder; PTSD: posttraumatic stress disorder

Source: Reference 35

Pharmacotherapy for anxiety disorders in older adults

Table 2

continued on page 70

Current Psychiatry

March 2011

Anxiety in

older adults

Bottom Line

Anxiety disorders often are underdiagnosed and undertreated in older adults,

especially when the clinical presentation of anxiety diers from that seen in younger

adults. Late-life anxiety symptoms may be a manifestation of stresses/losses,

depression, coexisting medical problems, substance abuse, medication/herb side

eects, withdrawal syndromes, or general disability. Eective treatment may include

pharmacotherapy, psychotherapy, and complementary and alternative therapies.

Selective serotonin reuptake inhibitors

(SSRIs) and serotonin-norepinephrine

reuptake inhibitors (SNRIs) generally

are safe and produce fewer side effects

compared with tricyclic antidepressants

(TCAs), especially in geriatric patients.

SSRIs and SNRIs may be useful for GAD,

PD, OCD, and PTSD in older patients.

TCAs can effectively treat anxiety symp-

toms but may be cardiotoxic and their

anticholinergic properties can lead to se-

rious side effects. Benzodiazepines often

are used for acute or short-term anxiety

management, but chronic use in geriatric

patients can cause cognitive impairment,

falls, and other serious side effects. Buspi-

rone may be benecial for GAD but is not

effective for PD.

The drug is well toler-

ated in older persons, but may take 2 to 4

weeks to be effective (Table 2, page 68).

Pharmacotherapy for anxiety disorders

in geriatric patients often is used in conjunc-

tion with psychotherapy. Psychotherapeu-

tic approaches include cognitive-behavioral

therapy (CBT), exposure therapy, dialecti-

cal behavioral therapy, and interpersonal

therapy. Increasing evidence supports the

effectiveness of psychotherapy in treating

anxiety disorders in younger adults as well

as in older patients, often in combination

with pharmacotherapy.

In older patients

with GAD, CBT is associated with a greater

improvement in worry severity, depressive

symptoms, and overall mental health com-

pared with usual care.

In addition to traditional pharmaco-

therapy, complementary and alternative

therapies often are used for late-life anxi-

ety. These therapies include biofeedback,

progressive relaxation, acupuncture, yoga,

massage therapy, art, music, or dance

therapy, meditation, prayer, and spiritual

counseling.

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Clinical Point

SSRIs and SNRIs may

be useful for several

anxiety disorders in

older patients; TCAs

may be cardiotoxic

and can lead to

serious side eects

Related Resources

• Wetherell JL, Lenze EJ, Stanley MA. Evidence-based

treatment of geriatric anxiety disorders. Psychiatr Clin

North Am. 2005;28(4):871-896,ix.

• Lenze EJ, Wetherell JL. Anxiety disorders. In: Blazer DG,

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Drug Brand Name

Buspirone • BuSpar

Disclosure

The authors report no nancial relationship with any company

whose products are mentioned in this article, or with

manufacturers of competing products.

continued from page 68

Current Psychiatry

Vol. 10, No. 3

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Clinical Point

In older patients with

GAD, CBT is associated

with improvements

in worry severity,

depressive symptoms,

and overall mental

health

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risk factors. Am J Psychiatry. 2000;157(1):89-95.

b. Goodwin RD. Anxiety disorders and the onset of depression among adults in the community. Psychol Med.

2002;32:1121-1124.

c. Merikangas KR, Zhang H, Avenevoli S, et al. Longitudinal trajectories of depression and anxiety in a prospective

community study: the Zurich Cohort Study. Arch Gen Psychiatry. 2003;60:993-1000.

d. DeLuca AK,Lenze EJ,Mulsant BH, et al. Comorbid anxiety disorder in late life depression: association with memory

decline over four years. Int J Geriatr Psychiatry.2005;20(9):848-854.

e. Merikangas KR, Kalaydjian A. Magnitude and impact of comorbidity of mental disorders from epidemiologic surveys. Curr

Opin Psychiatry. 2007;20:353-358.

f. Lenze E, Mulsant BH, Shear MK, et al. Comorbid anxiety disorders in depressed elderly patients. Am J Psychiatry.

2000;157:722-728.