The Silent Geriatric Giant: Anxiety Disorders in Late Life

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

Disclosures

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

In This Article

Differences in Anxiety Disorder Presentations in Late Life

The most common disorder in late life is GAD, which is characterized by >6 months of worry about a number of life domains (e.g., relationships, finances, and health), difficulty in controlling the worry, and associated physical symptoms such as restlessness, fatigue, muscle tension, and insomnia that interfere with social or occupational functioning. A new onset of GAD among older adults is often related to a depressive disorder. The combination of major depressive disorder and GAD has a worse prognosis overall, requiring 50% more time to respond to treatment and incomplete recovery from the depression.[10]

Specific phobias are characterized by persistent irrational fear of a situation, object, or activity and the desire to avoid the phobic situation. Among individuals over 65 years, agoraphobia is the most common of phobias, representing up to 80% of new-onset cases in late life[11]; unlike agoraphobia in younger patients, in older adults it does not always occur with a concurrent panic disorder but can follow a traumatic event such as medical illness, mugging, or a fall.[12] The fear of falling is much more common among older adults than in young patients, occurring in 30-77% of older adults who have fallen, and it is associated with becoming housebound, worsening depression, and the impediment of rehabilitation after a fall.[13]

Regarding the other three major anxiety disorders, panic disorder and obsessive compulsive disorder are more likely to appear among older adults who have a comorbid medical illness or dementia, and to have different clinical presentations than in younger individuals. Among older adults, panic may present with more shortness of breath but fewer physical symptoms overall. Older adults with obsessive compulsive disorder describe more themes of sins and religion than infections or contamination compared with younger persons; and in those with dementia, perseveration about toileting and medication schedules are common themes.[14] Posttraumatic stress disorder is as likely to develop in older adults following a traumatic event as in younger patients, but there are cohort differences in experiences for older adults, such as the Holocaust and the World Wars. Traumatic memories may be reactivated by news of war and by personal losses, such as bereavement, diminished health, or retirement[15] or in the context of dementia when short-term memory loss leads to increased rumination about past traumas.

Anxiety disorders are linked with increased morbidity and mortality among individuals who have medical illness, and the presence of medical illness increases the risk of anxiety disorders.[16] Table 3 presents common medical issues related to anxiety in late life. Table 4 outlines some suggested investigations. Individuals with dementia who have anxiety often show their emotions indirectly through physical signs (tension, restlessness, fidgeting, agitation, sleep disturbance, wringing hands) and through their countenance (anxious or worried appearance).

Older adults are also more likely than younger adults to be taking multiple medications, some of which may cause or exacerbate anxiety disorders. A careful review of the list of medications is important in evaluating anxiety disorders among older adults, especially before prescribing additional medications for treatment ( Table 5 ).

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