Anxiety Disorders Under-Recognized in Older Americans
ADAA Experts Offer Tips for Identifying Disorders, Helping Loved Ones

It's a fact: Americans are getting older. The fastest growing segment of the U.S. population is people ages 85 and older. What's more, the number of people ages 65 and over is expected to double in size within the next 25 years - to almost 1-out-of-5 Americans - or about 72 million people!

This shift has brought seniors' issues to the forefront. But while we are continually making medical advances that help people live longer lives, little research has focused on anxiety disorders in the elderly, treatment of which can help people live healthier, happier lives. These disorders can first occur later in life, or can reappear in seniors from years earlier, when they may have been identified as "spells" or "nerves" and treatment wasn't offered or available.

We asked ADAA members Eric Lenze, M.D., of the Western Psychiatric Institute and Clinic at the University of Pittsburgh Medical Center, and Julie Wetherell, Ph.D., of the University of California-San Diego and VA San Diego Healthcare System - two experts on anxiety in the elderly - to answer some frequently asked questions from both caretakers and elderly patients.

1) What signs should a caretaker look for to suggest that a family member may have an anxiety disorder?

Dr. Wetherell: Excessive and hard to control worry that causes distress or interferes with the person's life is the hallmark of generalized anxiety disorder (GAD), which is the most common anxiety disorder in older adults. Other common symptoms to look for in older adults include trouble sleeping, fatigue and muscle tension, which are often discounted as features of normal aging. Also, many older adults with anxiety are sensitive to physical symptoms, so they may visit doctors often even when told there is nothing physically wrong.

2) What tips can you give to caretakers and family who want to help?

Dr. Lenze: Short-term anxiety (less than a month) may pass on its own, but chronic anxiety (greater than six months) is very likely to continue without treatment. Helping a family member get treatment is important. It is equally essential to make sure they actually stay in treatment and follow it. Caretakers who suspect anxiety might be a problem should contact the elderly person's doctor or a mental health specialist, preferably someone who specializes in geriatrics.

3) Why is it difficult to identify an anxiety disorder in an older patient?

Dr. Wetherell: Older adults with anxiety usually don't seek help. Other factors that make it difficult include:

• Anxiety symptoms can mimic medical conditions and side effects from certain medications;
  
• Many older adults typically go to their primary care doctor, who may not have either the time or the specialized knowledge to detect and diagnose anxiety disorders;
  
• Mental health professionals see very few older adults with anxiety disorders, so they tend to assume anxiety is not a very common problem in later life and often don't recognize it; and
  
• Tests for anxiety disorders were not developed with older adults in mind.

4) How common are anxiety disorders in the elderly?

Dr. Wetherell: Anxiety disorders overall are the most common mental health problem among older adults. Approximately 1 in 10 older adults has an anxiety disorder, with twice as many experiencing significant levels of anxiety symptoms. As mentioned above, GAD, which studies indicate affects between 3 to 7 percent of older adults, is by far the most common anxiety disorder in older people, and is probably more common than major depression.

5) Do elderly patients have particular life circumstances, unique concerns or other social, physical or biological factors that make them prone to developing an anxiety disorder?

Dr. Lenze: Recent research suggests that there are factors with aging such as social changes (e.g., retirement), medical concerns (particularly chronic or traumatic medical conditions) or brain changes (e.g., due to vascular illness or Alzheimer's disease) that may increase the risk for developing an anxiety disorder. In a recent study of elderly patients with GAD, for example, about one half developed the disorder late in life (50s or later). However, more research needs to be done.

6) What differences exist in anxiety in older patients versus younger patients?

Dr. Lenze: One unique issue about anxiety in older adults is its association, even with fairly mild levels of anxiety, with cognitive impairment, particularly memory and attention. It is not clear, however, whether this means that treating anxiety disorders in older adults results in cognitive improvement. As with other psychiatric illnesses, anxiety disorders in older adults are also more likely to co-occur with (likely multiple) medical problems. However, it is less likely to co-occur with substance or alcohol abuse in older adults.

7) What treatment options are available? Are there special considerations or other issues that factor in to treating elderly people?

Dr. Lenze on Medications: As with all prescription medications, individuals must talk with their doctors to identify the right medication and treatment. There is no one treatment that works for everyone. Often the biggest challenge with treatment is convincing the patient to take the medicine and not quit it within a couple of weeks. Caretakers can be essential in being the doctor's facilitator in getting a patient to take, and stay on, a medication. Treatment options include:

• Benzodiazepines. Benzodiazepines (e.g., diazepam, alprazolam) are the most common medications used in elderly persons with anxiety disorders. This seems to be the only treatment in which elderly persons are "ahead of the curve." Unfortunately, these medications hold risks for elderly persons, including falls, injuries and cognitive impairment. Long-term use of benzodiazepines may not be recommended.
• Selective Serotonin Reuptake Inhibitors (SSRIs). SSRIs have been shown to be highly effective in treating anxiety disorders.
• Atypical Antipsychotics. Some research has looked at using atypical antipsychotics as an adjunct for late-life anxiety disorders that don't respond fully to SSRIs. However, recent information about potential stroke and mortality risks for these medications in elderly persons with dementia makes them perhaps less attractive in such "off label" use.

Dr. Wetherell on Therapy: Research has shown that cognitive-behavioral therapy (CBT) is effective in the treatment of anxiety disorders. In CBT, a mental health professional helps a patient become aware of their problem thoughts or behaviors and then guides them to try alternative behaviors. The therapy focuses on developing positive thinking and behavior patterns as opposed to the negative ones. Sometimes combination therapies, using both medication and CBT, are recommended.

Older adults in therapy may have some special needs. Questions a caretaker or older adult should ask before the course of therapy begins include the following:

• Have alternative causes of anxiety, such as medical conditions and the side effects of medications, been ruled out?
  
• Do you provide educational materials about anxiety and psychotherapy?
  
• Do you provide special accommodations for elderly patients, such as printed materials with larger fonts, an accessible office and furniture that is comfortable for older adults?
  
• Do you offer flexible scheduling (so older patients can avoid traffic or work around other health care appointments)?
  
• Do you expect patients to practice at home?
  
• Do you follow-up with reminder/trouble-shooting phone calls to improve adherence to at-home assignments?

8) Are there techniques that you recommend for elderly people to help them reduce their anxiety on a daily basis?

Dr. Wetherell: Relaxation techniques, practiced daily, can help with sleep as well as with general tension and anxiety levels. The simplest relaxation technique is slow, deep breathing. Another popular technique is guided imagery, which is basically like daydreaming. I suggest that people close their eyes and imagine that they are in a calm, safe place. It can be a place they've actually been, like a cabin in the mountains, or a place they've only imagined, like floating on a fluffy white cloud. It is most helpful for people to use all their senses when thinking about that place, so I will ask them to describe to themselves what they see, who (if anyone) is with them, what they hear, what they feel on their skin, what they smell and what they taste.

9) What questions should a caregiver ask a doctor?

Dr. Wetherell: Important questions caregivers should ask are:

• Could these symptoms be the result of an anxiety disorder?
  
• Could treating the anxiety disorder improve my family member's functioning or quality of life, even if the person also has a chronic medical illness like diabetes or a heart condition that can cause anxiety-like symptoms?
  
• Would medication be appropriate for my family member?
  
• How will medication affect other medications my family member is taking?
  
• How long will my family member be in treatment?
  
• Do you know of any support groups for older individuals with an anxiety disorder?
  
• Do you have a referral for a geriatric psychiatrist or another type of geriatric mental health professional?

Dr. Lenze: To help a family member or yourself, learn about all treatment options and ask about their risks and benefits. If a patient is started on medication, making sure that there is adequate follow-up is key; usually patients should visit the doctor one to two weeks after starting medication. It's important that the patient and caregiver know who to call to discuss any side effects or questions they may have from the medication.

10) If an older relative or friend never spoke of having an anxiety disorder, why does it seem to suddenly appear now so late in life?

Dr. Wetherell: Health problems, physical limitations, cognitive impairment and stressful life events, such as a spouse's illness or death, can all trigger anxiety in older people. For some who have managed anxiety all their lives by keeping busy, retirement or a slower pace of life can cause anxiety to become a problem.

11) What is the difference between an older patient with depression and with an anxiety disorder? Do these occur together?

Dr. Lenze: The experience of an anxiety disorder and the experience of depression are different. Most people can tell when they feel anxious and when they feel sad, and recognize that these are different emotions. The course of GAD (more chronic) is different than that of major depression (more episodic).
It is likely there is a common neurobiological basis for anxiety disorders and depression, given that they involve similar cognitive processes and that treatments helpful for one typically help the other. Some have argued that the anxiety disorders (particularly GAD and panic) and depression might be best understood by this common ground.

Anxiety disorders and depressive disorders can occur together. When they do co-exist in an elderly person, the resulting condition is more severe, with greater likelihood of suicidal thoughts. When both an anxiety disorder and depression occur, they appear to be more difficult to treat with standard antidepressants. Much more research is needed on how to treat anxious depression when it is resistant to standard treatments, and even prevent it from occurring in the first place.

Eric J. Lenze, M.D., is Associate Professor in the Department of Psychiatry at the Western Psychiatric Institute and Clinic at the University of Pittsburgh Medical Center. He is the creator of the website www.latelifedepression.org, an information resource for late-life depression, anxiety disorders, bipolar disorder, insomnia and grief. Dr. Lenze is a local, national and international speaker on topics including late-life generalized anxiety disorder and depression in medically rehabilitating elderly patients.

Julie Loebach Wetherell, Ph.D., is Assistant Professor in Residence in the Department of Psychiatry at the University of California, San Diego, and Staff Psychologist at the VA San Diego Healthcare System. Dr. Wetherell writes and gives talks about late-life anxiety and chronic pain.

Additional Resources:

American Association for Geriatric Psychiatry

Late Life Depression Evaluation and Treatment Center, University of Pittsburgh Medical Center