New Thinking on Anxiety and Aging: Anxiety Disorders Common in the Elderly

New Thinking on Anxiety and Aging:
Anxiety Disorders Common in the Elderly
By Stephanie Sampson, M.A.

Sadly, older people must deal with significant changes-from threats to their physical and financial independence to loss of spouses and friends-at a time when they are often least equipped to deal with them. "People's capacity to master change lessens as they age, and it is not surprising that all the changes older people experience may lead to anxiety," says Glenn Brynnes, Ph.D., M.D., a psychiatrist and co-director of North County Psychiatric Associates in Baltimore County, Md. "Nevertheless, we should not view worries or fears that impair a person's daily functioning as an 'expected' part of aging."

Anxiety in the elderly is not well understood. Research, on both the course and treatment of anxiety in older adults, lags behind that of other mental conditions, such as depression and Alzheimer's. Until recently, anxiety disorders were believed to decline with age.
But experts are beginning to recognize that aging and anxiety are not correlated: anxiety is as common in the old as in the young, although how and when it appears is distinctly different in older adults. "Anxiety disorders are just as real in the elderly as in younger people-and just as treatable," confirms Brynnes.

Late-life anxiety disorders have been underestimated for several reasons, according to experts. For example, older patients are less likely to report psychiatric symptoms and more likely to emphasize their physical complaints, and some major epidemiological studies have excluded GAD, one of the most prevalent anxiety disorders in older adults.

Not Just for the Young
While the prevalence of anxiety disorders was once believed to decline with age, recent studies show that anxiety is as common in the old as in the young. A study conducted in the Netherlands in 1998 with 3,056 adults aged 55-85 showed about 10 percent of the elderly have an anxiety disorder, within the range found in studies of younger populations. According to this Dutch study, published in the American Journal of Psychiatry by Aartjan Beekman, M.D., et al., generalized anxiety disorder was the most common anxiety disorder in this older group.

What accounts for the constant prevalence throughout the lifespan? It turns out that most older adults with an anxiety disorder had one when they were younger. (The exception being late-onset agoraphobia.) What "brings out" the anxiety are the stresses and vulnerabilities unique to the aging process: chronic physical problems, cognitive impairment and significant emotional losses.
"Someone with an anxiety disorder may have been able to 'manage' their anxiety when they were younger by manipulating their environment, perhaps by avoiding situations or by having a spouse do certain things for them," says Brynnes. "But if the spouse dies, for example, they are no longer able handle their anxiety and become dysfunctional."

The Dutch study, cited above, also confirmed that depression and anxiety go together in the elderly, as they do in the young, with almost half of those with major depression also meeting the criteria for anxiety and about one-quarter of those with anxiety meeting criteria for major depression. As with younger persons, being a woman and having less formal education are risk factors for anxiety in older adults.

Recognizing Anxiety in the Aging
Recognizing an anxiety disorder in an older person poses several challenges. Aging brings with it a higher prevalence of certain medical conditions, realistic concern about physical problems, and a higher use of prescription medications. As a result, separating a medical condition from physical symptoms of an anxiety disorder is more complicated in the older adult. Diagnosing anxiety in individuals with dementia can be difficult, too: agitation typical of dementia may be difficult to separate from anxiety; impaired memory may be interpreted as a sign of anxiety or dementia, and fears may be excessive or realistic depending on the person's situation.

"With aging often come aches, pains, distractability, embarassment about conditions such as incontinence, or just fear of that next heart attack," says Murray Stein, M.D., Professor in Residence in the Department of Psychiatry of the University of California at San Diego. "However, an anxiety disorder should be considered in any older patient with depressive symptoms or with physical symptoms that are not explained by a physical problem, such as chest pain, palpitations, shortness of breath, diarrhea or sleep problems." Physicians should suspect anxiety as the cause of physical symptoms if the symptoms have lasted for two years or more with little change, advises Stein.

"Sometimes, an older person is more willing to admit they have a physical problem-such as chest pain or sleep problems-than a psychological one," says Brynnes. "He or she may be searching for control at a time when control over many issues is being lost. Getting them to realize that the changes in their lives caused by excessive fear and worry are absolutely not something they have to accept is a key part of treatment."

Another facet of anxiety in the elderly that is gaining more attention is the possibility that what has previously been diagnosed as agitation in sufferers of Alzheimer's Disease and other types of dementia may, in fact, be anxiety. Anxiety-like symptoms in those with Alzheimer's may be triggered by exposure to various objects, people, or performance situations. Anxiety may manifest itself in cognitive symptoms (extreme frustration and fear of losing control), behavioral symptoms (restlessness and hyperkinesis) or physical symptoms (sweating and palpitations).

Some question the "capacity" for anxiety in those with limited cognition, however, the same question has not been raised about children, who also have an underdeveloped nervous system. "What may be operating in both cases…are right-brain phenomena, such as the role of intuition, sensing, interpreting or misinterpreting something that seems not right," says Gene D. Cohen, Ph.D. M.D., writing in the American Journal of Geriatric Psychiatry. Dr. Cohen goes on to say, "Both [a young child and the cognitively impaired] may have a limited capacity to tell you how they feel…but there are many examples in the case of anxiety where the diagnosis does not rely on what patients say, but rather on what they display. Overlooking the potential role of anxiety as clinically significant in Alzheimer's Disease is to overlook important intervention opportunities."

Treatment
Diagnosis and treatment in most cases should start with the primary care physician. "Going to a doctor they know and have a relationship with may be less stigmatizing for Mom or Grandpa and may increase the chances they will go along with treatment or a referral to a mental health professional," says Stein.

Both medication and psychosocial therapies are used to treat anxiety in older persons, although clinical research on their effectiveness is still limited. Anti-depressants (specifically the selective serotonin reuptake inhibitors or SSRIs), rather than anti-anxiety medication (such as the benzodiazepines), are the preferred medication for most anxiety disorders.

"SSRIs can treat the anxiety and depression that often coexist in the anxious older patient and are generally less likely to result in over-sedation, cognitive impairment, or physical dependence compared to other drugs used for anxiety," says Stein. Drug therapy may last a year or longer.

Cognitive Behavioral Therapy (CBT) is being used increasingly to reduce anxiety in older adults. CBT may involve relaxation training, cognitive restructuring (replacing anxiety-producing thoughts with more realistic, less catastrophic ones) and exposure (systematic encounters with feared objects or situations). CBT can take up to several months and has no side effects.

Success in treating anxiety in the older patient depends, in part, on a partnership between the patient, the family and the doctor. Everyone needs to agree on what the problem is and make a commitment to stick with treatment until the patient can return to normal functioning. Family members may need to advocate for the older person, ensuring that issues encountered during treatment-such as drug side effects-are dealt with promptly.

Getting Wiser
Mental illness in the elderly remains a poorly understood area, and researchers are just beginning to focus on anxiety disorders in this segment of the population. "We know that depression presents differently in older people-for example, older depressed patients are more likely to complain of physical rather than psychological symptoms-and these differences may also be true of anxiety in the aged, but we just don't have enough research yet to be sure," says Stein.

Fruitful avenues for future research include: (1) epidemiological studies, particularly longitudinal studies that will show the course of anxiety over the whole lifetime, (2) clinical trials for anti-anxiety drugs that include older adults already on other medications to get a more "real world" view of drug interactions and side effects; (3) controlled trials of CBT and other psychotherapies; and (4) improvements in diagnostic categories to include anxiety in dementia.

Additional Resources on Anxiety in the Elderly:
•ADAA website, www.adaa.org.
•American Association for Geriatric Psychiatry, www.aagponline.org, (301) 654-7850.
•"Anxiety in the Elderly," a website put together by Glenn Brynnes, Ph.D., M.D., features information and links, www.ncpamd.com/anxiety_aging.htm.
•Late Life Depression Evaluation and Treatment Center, University of Pittsburgh Medical Center, www.wpic.pitt.edu/research/depr, click on "anxiety."

A Question of Emphasis:
Diagnosing Anxiety in the Aging

Often the elderly are reluctant to report psychiatric problems. To help identify anxiety in patients and discover the pattern of the somatic symptoms, physicians may find it useful to phrase questions in the following way:

To identify anxiety:
• Have you been concerned about or fretting over a number of things?
•Is there anything going on in your life that is causing you concern?
• Do you find that you have a hard time putting things out of your mind?

To identify how and when physical symptoms began:
• What were you doing when you noticed the chest pain?
• What were you thinking about when you felt your heart start to race?
• When you can't sleep, what is usually going through your head?

Adapted from Ariel J. Lang, Ph.D., and Murray B. Stein, M.D., "Anxiety Disorders: How to Recognize and Treat the Medical Symptoms of Emotional Illness," Geriatrics. 2001 May; 56 (5): 24-27, 31-34.

Worried about an Aging Parent?

"Talking to your parent or loved one about any changes in their lives is still one of the best ways to find out if there is a problem," says Brynes, who is board certified in geriatric psychiatry. Ask your loved one about any changes you notice in the following:

• Daily routines and activities. Is Grandma refusing to do previously routine activities or avoiding social situations she used to enjoy?
• Worries. Does Dad seem to have more worries than before and do those worries seem out of proportion to reality (such as a real threat to his safety).
• Medication. Has Mom recently started taking another medicine? Is she using more of a particular medication than before? Medication side effects (such as breathing problems, irregular heartbeat, or tremors) can simulate symptoms of anxiety. Also, an increased use of medication (or alcohol) may indicate an attempt to "self-medicate."
• Overall mood. Depression and anxiety often occur together. Tearfulness, apathy, and a loss of interest in formerly enjoyable activities are possible signs of depression.

"You aren't trying to diagnose anything, just determine if help is needed. In most cases, if you think there's a problem, there probably is, even if your loved one may not admit it just now," says Glenn Brynes, Ph.D., M.D.