Anxiety Disorders in Older Adults

Research on the course and treatment of anxiety in older adults lags behind that of other mental conditions such as depression and Alzheimer's. Until a few years ago, anxiety disorders were believed to decline with age. But now experts are beginning to recognize that aging and anxiety are not mutually exclusive: Anxiety is as common among the old as among the young, although how and when it appears is distinctly different.

Anxiety disorders in the older adult population are real and treatable, just as they are in younger people. Another commonality between old and young is the high incidence of depression with anxiety. Depression and anxiety go together; almost half of those with major depression also meet the criteria for anxiety, and about one-quarter of those with anxiety meet the criteria for major depression. As with younger people, being a woman and having less formal education are risk factors for anxiety in older adults.

Most older adults with an anxiety disorder had one when they were younger. What brings out the anxiety are the stresses and vulnerabilities unique to the aging process: chronic physical problems, cognitive impairment, and significant emotional losses.

Late-life anxiety disorders have been underestimated, according to experts, because older patients are less likely to report psychiatric symptoms and more likely to emphasize their physical complaints. And some major epidemiological studies have excluded generalized anxiety disorder, one of the most prevalent anxiety disorders in older adults.

Recognizing Anxiety
Recognizing an anxiety disorder in an older adult poses several challenges. Aging brings with it a higher prevalence of many 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. Diagnosing anxiety in people 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.

Treatment
Diagnosis and treatment should start with the primary care physician. Many older people feel more comfortable talking to a doctor with whom they already have a relationship. If they trust their primary care physician, chances are greter that they will accept treatment or a referral to a mental health professional.

Medication and psychosocial therapies are used to treat anxiety in older persons, although clinical research on their effectiveness is still limited. Antidepressants (specifically the selective serotonin reuptake inhibitors, or SSRIs), rather than anti-anxiety medication (such as the benzodiazepines), are preferred for most anxiety disorders. Cognitive-behavioral therapy (CBT), used increasingly to reduce anxiety in older adults, may involve relaxation training, cognitive restructuring (replacing anxiety-producing thoughts with more realistic, positive ones), and exposure (systematic encounters with feared objects or situations). CBT often takes several months and has no side effects.

Success in treating anxiety in an older adult depends on a partnership between the patient, the family, and the doctor. Everyone must agree on the nature of the problem and make a commitment to stick with treatment until the person returns to normal functioning. Family members may need to advocate for an older person to make sure that drug side effects and other issues encountered during treatment are managed promptly.

For more information, see Guide to Treatment.

Diagnosing Anxiety in Older Adults
Older adults are often reluctant to report psychiatric problems. To help identify anxiety, it may be useful to phrase questions in the following way:

To identify anxiety

• Have you been concerned about or fretted 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?

Worried About an Aging Parent?
Talking to older parents or loved ones about changes in their lives is one of the best ways to find out about problems. Ask about any changes you notice in the following areas:

• Daily routines and activities. Is Grandma refusing to do routine activities or avoiding social situations she used to enjoy?
• Worries. Does Dad seem to have more worries than before? If so, 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? Side effects, such as breathing problems, irregular heartbeat, or tremors, can simulate symptoms of anxiety. 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.