The Silent Geriatric Giant: Anxiety Disorders in Late Life

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


Geriatrics and Aging. 2008;11(3):150-156. 

In This Article

Abstract and Introduction

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.

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.

Areas of the Brain Affected by Generalized Anxiety Disorder


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