From Geriatrics & Aging

The Silent Geriatric Giant: Anxiety Disorders in Late Life

Keri-Leigh Cassidy, MD; Neil A. Rector, PhD

Posted: 09/26/2008; Geriatrics and Aging. 2008;11(3):150-156. © 2008  1453987 Ontario, Ltd.

 

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Abstract and Introduction

Abstract

Late-life anxiety can often be "silent"—missed or difficult to diagnose as older adults tend to somatize psychiatric problems; have multiple psychiatric, medical, and medication issues; and present anxiety differently than do younger patients. Yet late-life anxiety disorders are a "geriatric giant," being twice as prevalent as dementia among older adults, and four to eight times more prevalent than major depressive disorders, causing significant impact on the quality of life, morbidity, and mortality of older adults. Treatment of late-life anxiety is a challenge given concerns about medication side effects in older, frail, or medically ill patients. Antidepressants are recommended but not always tolerated, and benzodiazepines are generally to be avoided in this population. Effective psychotherapies such as cognitive behavioural therapy (CBT) are of particular interest for the older adult population, and the combination of CBT and medication is often needed to optimize treatment.

Introduction

Anxiety disorders have historically been considered a problem of childhood and early adulthood, with a peak onset between 18 and 40 years. Yet, anxiety disorders surpass the other well-known "geriatric giants" in their prevalence among older adults (10-20%), being twice as common as the dementias (8%) and four to eight times more prevalent than major depressive disorder (1-3%).[1] They are the most common psychiatric disorders throughout the lifespan.

Anxiety disorders are often "silent," being difficult to diagnose or missed entirely. Of the five principal anxiety disorders, 90% of presentations of late-life anxiety are accounted for by either generalized anxiety disorder (GAD) or a specific phobia,[2] with GAD representing at least 50% of cases among older adults,[3] of which the majority are earlier-onset disorders with late-life exacerbations (50-97%).[4] The remaining 10% of anxiety disorders are accounted for by obsessive-compulsive, post-traumatic stress, and panic disorders.

Associated cognitive aspects of underlying anxiety disorders include hypervigilance to threat, seeing oneself as vulnerable, and perceiving the demands of life as exceeding the available resources to cope.[5] Older adults are at risk for anxiety disorders.[5] Increasing frailty, medical illness, and losses can contribute to feelings of vulnerability and fear, and can reactivate anxiety disorders. A lack of social supports, a recent traumatic event, medical illnesses and medications, poor self-rated health, the presence of another psychiatric illness (particularly another anxiety disorder or depression), an early-onset anxiety disorder, and female gender[6] are all risk factors for late-life anxiety disorders.

Figure 1 presents areas of the brain affected by GAD.

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Figure 1.

Areas of the Brain Affected by Generalized Anxiety Disorder
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Figure 1.

Areas of the Brain Affected by Generalized Anxiety Disorder
 
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References

  1. Regier DA, Boyd JH, Burke JD, et al. One month prevalence of mental disorders in the US—based on five epidemiologic catchment area sites. Arch Gen Psychiatry 1988;45:977-86.
  2. Krasucki C, Howard R, Mann A. Anxiety and its treatment in the elderly. Int Psychogeriatr 1999;11:25-45.
  3. Ferretti G. Anxiety and Alzheimer's disease. J Geriatr Psychiatry Neurol 2001;14:52-8.
  4. McCurry SM, Gibbons LE, Logsdon RG, et al. Anxiety and nighttime behavioural disturbances. Awakenings in patients with Alzheimer's disease. J Gerontol Nurs 2004;30:12-20.
  5. Beck AT, Emery G, Greenberg RL, et al. Anxiety disorders and phobias: a cognitive perspective. New York: Basic Books, 1985.
  6. DeBours E, Beekman A, Geerlings S, et al. On becoming depressed or anxious in late life: similar vulnerability factors but different effects of stressful life events. Br J Psychiatry 2001;179:426-31.
  7. Greenberg PE, Sisitsky T, Kessler RC, et al. The economic burden of anxiety in the 1990s. J Clin Psychiatry 1999;60:427-35.
  8. Gallagher-Thompson D, Steffen A, Thompson LW, et al. Handbook of Behavioral and Cognitive Therapies with Older Adults. New York: Springer, 2007.
  9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (Revised 4th edition). Washington, DC: APA; 2000.
  10. Lenze E, Mulsant BH, Shear MK, et al. Comorbidity of depression and anxiety disorders in later life. Depression and Anxiety 2001;14;86-93.
  11. Livingston G, Watkin V, Milne B, et al. The natural history of depression and the anxiety disorders in older people: The Islington community study. J Affect Disord, Special Issue: Ageing 1997;46:255-62.
  12. Oxman TE, Barrett JE, Barrett J, et al. Psychiatric symptoms in the elderly in a primary care practice. Gen Hosp Psychiatry 1987;9:167-73.
  13. Kressig R, Wolf SL, Sattin RW, et al. Associations of demographic, functional, and behavioral characteristics with activity-related fear of falling among older adults transitioning to frailty. Age Ageing 2001:1456-62.
  14. Kohn R, Westlake RJ, Rasmussen SA, et al. Clinical features of obsessive-compulsive disorder in elderly patients. Am J Geriatr Psychiatry 1997;5:211-15.
  15. Kaup BA, Ruskin PE, Nyman G. Significant life events and PTSD in elderly World War II veterans. Am J Geriatr Psychiatry 1994;2:239-43.
  16. Kvaal K, Macijauskiene J, Engedal K, et al. High prevalence of anxiety symptoms in hospitalized geriatric patients. Int J Geriatr Psychiatry 2001;16:690-3.
  17. Krasucki C, Howard R, Mann A, et al. Anxiety in the elderly: anxiety and its treatment in the elderly. Int Psychogeriatr 1999;11:25-45.
  18. Health Canada. Statistics on death rate from falls per 100,000 by age. Public Health Agency of Canada, 2005; http://www.phac-aspc.gc.ca/seniors-aines/pubs/seniors_falls/chapter2-2_e.htm#sec24.
  19. Lenze EJ, Mulsant BH, Shear MK, et al. Efficacy and tolerability of citalopram in the treatment of late-life anxiety disorders: results from an 8-week randomized, placebo-controlled trial. Am J Psychiatry 2005;162:146-50.
  20. Katz IR, Reynolds CF III, Alexopoulos GS, et al. Venla-faxine ER as a treatment for generalized anxiety disorder in older adults: pooled analysis of five randomized placebo-controlled clinical trials. J Am Geriatr Soc 2002;50:18-25.
  21. Nyth Al, Gottfries CG. The clinical efficacy of citalopram in treatment of emotional disturbances in dementia disorders: A Nordic multicentre study. Br J Psychiatry 1990;157:894-901.
  22. Gauthier S, Feldman H, Hecker J, et al. Efficacy of donepezil on behavioral symptoms in patients with moderate to severe Alzheimer's disease. Int Psychogeriatr 2002;14:389-404.
  23. Monsch AU, Giannakopoulos P; GAL-SUI Study Group. Effect of galantamine on behavioural and psychological disturbances and caregiver burden in patients with Alzheimer's disease. Curr Med Res Opin 2004;20:931-8.
  24. Barrowclough C, King P, Colville J, et al. A randomized trial of the effectiveness of cognitive-behavioral therapy and supportive counselling for anxiety symptoms in older adults. J Consult Psychol 2001;69:756-62.
  25. 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.
  26. Ursuliak Z, Cassidy KL, Eskes G, et al. An observational study of the effectiveness of group cognitive behavioural therapy for late-life depressive and anxiety disorders. Can J Geriatr. In press.
  27. Banazak D. Anxiety disorders in elderly patients. J Am Board Fam Pract 1997;10:280-9.
  28. Carmin CN, Wiegartz PS, Scher C. Anxiety disorders in the elderly. Curr Psychiatry Rep 2000:2;13-9.
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Table 1. Psychiatric Sources of Anxiety

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Table 2. Anxiety Scales

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Table 3. Medical Conditions Associated with Late-Life Anxiety

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Table 4. Investigations for Late-life Anxiety Disorders

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Table 5. Drugs Associated with Late-Life Anxiety

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Table 6. CANMAT Guidelines for the Pharmacological Treatment of Anxiety Disorders

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Authors and Disclosures

Keri-Leigh Cassidy, MD, Department of Psychiatry, Dalhousie University, Halifax, NS; Department of Psychiatry, University of Toronto, Toronto, ON.

Neil A. Rector, PhD, Department of Psychiatry, University of Toronto, Toronto, ON.

Disclosure: No competing financial interests declared.

 
 
 
 
 
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