Sleeping Geriatric Giant: Anxiety Disorders in Older Adults, Part 1

– Posted in: Anxiety

Anxiety Disorders in older adults is a huge problem that has been ignored, causing a great deal of unnecessary suffering.

Research on older adults’ Anxiety Disorders 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 Anxiety is as common in the old as in the young, although how and when it appears is distinctly different in older adults.

Sadly, because of the lack of information on Anxiety Disorders in older adults, especially in how to diagnose them, many go undiagnosed and untreated. James Maddux and Barbara Winstead state: 1

[I]n comparison to other diagnoses (e.g. depression) less is known about the etiology [causes], including clinical characteristics, course, treatment, and prognosis of anxiety disorders in late life. … Because anxiety disorders are difficult to diagnose in older adults, they are often undiagnosed.

Yet, late-life Anxiety Disorders are what Keri-Leigh Cassidy and Neil Rector call a “sleeping geriatric giant.” Anxiety Disorders are twice as prevalent as dementia among older adults, and 4 to 8 times more prevalent than major depressive disorders, causing significant impact on the quality of life, morbidity, and mortality of older adults.2

The annual U.S. health care costs due to late-life Anxiety Disorders in 1990 was estimated to be $42.3 billion. The numbers are surely higher now, and likely to go higher yet as the Baby Boomer generation grows older.3

This post is the first in a two-part series on the Anxiety Disorders in older adults. Tomorrow’s post addresses the diagnosis and treatment of Anxiety Disorders, and gives some tips on how to tell if your parent or loved one is suffering from them. This post covers the following topics:

  • How prevalent are Anxiety Disorders in older adults?
  • What are the most common Anxiety Disorders in older adults?
  • Anxiety Disorders in older adults are strongly linked with depression
  • What are the risk factors for Anxiety Disorders in older adults?

How prevalent are Anxiety Disorders in older adults?

Most would say depression is most prevalent, but they are wrong

If asked, most people would say that depression is the most prevalent of the mental illnesses late in life. However, this is not true. Maddux and Winstead say,{{4}}

Given the number of psychosocial losses that an older adult is likely to experience, one might assume that depression is the most common psychological disorder among older adults, however, research has shown that anxiety disorders are actually more prevalent.

Anxiety Disorders occur in up to 11 percent of adults aged 55 years and older, and Anxiety symptoms that do not meet criteria for a disorder affect 17 percent of older men, and 21 percent of older women.{{5}} {{6}} Many researchers believe these numbers are significantly underestimated for reasons discussed in part 2 of this series under “Why are Anxiety Disorders so hard to diagnose in older adults?”.

Increased rates of Anxiety Disorders are typical for older adults with a medical illness, as is higher prevalence among the homebound, nursing home residents, and patients with chronic illness. Anxiety symptoms are reported in as many as 40 percent of older patients with disabilities or chronic medical conditions. Poor health outcomes are associated with Anxiety, including:{{7}}

  • Decreased levels of physical activity 
  • Poorer perception of health, memory difficulties
  • Increased dependence
  • Increased rates of coronary artery disease and mortality

Anxiety is also pervasive in older adults with dementia. Symptoms of Anxiety occur in up to 71 percent of patients with dementia, and up to 21 percent have a diagnosable Anxiety Disorder.{{8}}

What are the most common Anxiety Disorders in older adults?

Generalized Anxiety Disorder is the most common

Generalized Anxiety Disorder (GAD) is characterized by persistent worry and associated physical symptoms lasting 6 months or longer. It is the most common of the Anxiety Disorders in later life, accounting for at least 50 percent of late-life Anxieties.{{9}} Its prevalence is 11 percent in older patients using primary care physicians.{{10}}

In 1999, the Surgeon General, David Satcher, reported on the mental health of older adults in the United States. The information he had available at the time dated from the 1980’s through the 1990’s, before the current surge in interest in the Anxiety Disorders, His estimates, however, have generally held up over time.{{11}} Satcher’s estimates of the other Anxiety Disorders were:{{12}}

Agoraphobia is the most common of phobias among people over 65 years, representing up to 80% of new cases in late life. Unlike Agoraphobia in younger individuals, 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.{{13}}

Many 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, such as chronic physical problems, cognitive impairment, and significant emotional losses.{{14}}

In addition, some people have untreated and continuing Anxiety Disorders from past years. Glenn Brynnes, Ph.D., M.D., a psychiatrist and co-director of North County Psychiatric Associates in Baltimore County, Maryland, says:{{15}} 

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. But if the spouse dies, for example, they are no longer able handle their anxiety and become dysfunctional.

Anxiety Disorders in older adults are strongly linked with depression

Depression and Anxiety go together in the elderly

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 Disorders.{{16}} About 30 percent of those with Anxiety Disorders also meet the criteria for major depression.{{17}}

Older adults with Anxiety Disorders and depression use more services, experience reduced quality of life and increased disability, have more severe physical symptoms, and have greater suicidal ideation. They are much harder to diagnose and treat than those with an Anxiety Disorder or depression alone. Key components for telling whether a patient has depression or an Anxiety Disorder include which set of symptoms came first, the severity of either depression or Anxiety, and the prominence of fear or sadness.{{18}} Diagnosis of Anxiety Disorders is discussed in depth in Part 2 of this series.

Generalized Anxiety Disorder (GAD) often precedes an episode of depression, which suggests that it may be a risk factor. 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.{{19}}

What are the risk factors for Anxiety Disorders in older adults?

Feelings of vulnerability activate Anxiety Disorders

Increasing frailty, medical illness, and losses can contribute to feelings of vulnerability and fear, and can activate or reactivate Anxiety Disorders. Associated thought patterns 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.

The following risk factors were compiled from a number of sources. The risk factors listed were determined by systematic reviews of the research literature and through surveys of older persons. The most prominent risk factors for Anxiety Disorders in older adults are:{{20}} {{21}} {{22}}

  • One or more chronic medical conditions
  • Physical disability or mobility impairment
  • Low physical activity
  • Prior Anxiety Disorder
  • Presence of another psychiatric illness (particularly another Anxiety Disorder, such as GAD, or depression)
  • Psychological stressors
  • Negative life events such as bereavement, retirement, financial problems
  • Recent traumatic event such as a fall, a mugging, or onset of a serious medical condition
  • Poor self-rated health
  • Medications
  • Sleep disturbance
  • Female gender
  • Lower levels of formal education
  • Lack of adequate support network
  • Fewer than 3 close friends or relatives
  • Those who are somewhat satisfied or not satisfied with friendships

Don’t miss the next part of the series!

Part 2 of the series addresses the diagnosis and treatment of Anxiety Disorders, and gives some tips on how to tell if your parent or loved one is suffering from them. The topics discussed are:

  • Why are Anxiety Disorders so hard to diagnose in older adults?
  • Overview of treatment of Anxiety Disorders in older adults
  • Medications for Anxiety Disorders in older adults
  • Therapy for Anxiety Disorders in older adults
  • Asking the right questions to diagnose Anxiety
  • Worried about an aging parent or loved one?

What do you think?

With life spans that are continuing to lengthen, many people will experience a third of their lives past the retirement age of 65. Yet, as with so many other medical and social matters in our society, the needs of the elderly have been virtually invisible to the mental health community. Older adults have most of the same mental problems that younger people do, but in different ways, and these different ways are just now beginning to be studied. 

I find it amazing that, until recently, it was thought that Anxiety Disorders decreased as one ages, or that psychotherapy was not recommended for older adults! In the face of the statistics, this shows — at least in my opinion — how much older adults have been ignored, or even worse, the ugly head of ageism.

  • Do you know an older person who has had Anxiety Disorders?
  • Do you think that ageism has anything to do with the delay in studying the mental problems of older people?
  • Have any of the topics discussed in this post “rung a bell?”

As always, your comments are welcome!

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FOOTNOTES

1. Maddux, James; Winstead, Barbara. Psychopathology. New York: Routledge, Taylor and Francis Group. 2008. p420

2. Cassidy, Keri-Leigh; Rector, Neil. (2008, April). The Silent Geriatric Giant: Anxiety Disorders in Late Life. Retrieved November 21, 2008 from Geriatrics & Aging (PDF): http://oscarresourceplone.oscartools.org/ltc/educators-resource/mental-health/1103anxiety.pdf  p150 ¶1

3. Cassidy, Rector. p150 ¶5

[[4]]Maddux, Winstead. p.420 ¶2[[4]]

[[5]]Calleo, Jessica; Stanley, Jessica. (2008, July 1). Anxiety Disorders in Later Life. Retrieved November 21, 2008 from Psychiatric Times: http://www.psychiatrictimes.com/anxiety/article/10168/1166976  ¶1[[5]] 

[[6]]Satcher, David. (1999). Mental Health: A Report of the Surgeon General 1999, Other Mental Disorders in Older Adults (Chapter 5). Retrieved November 21, 2008 from US Department of Health and Human Services (PDF): http://www.surgeongeneral.gov/library/mentalhealth/pdfs/c5.pdf p.364 [[6]]

[[7]]Calleo, Stanley. ¶2 [[7]]

[[8]]Calleo, Stanley. ¶3 [[8]]

[[9]]Cassidy, Rector. p150 ¶3 [[9]]

[[10]]Calleo, Stanley. ¶1 [[10]]

[[11]] Cassidy, Rector. p150 ¶3 [[11]]

[[12]]Satcher. p. 336 [[12]]

[[13]]Cassidy, Rector. p152 ¶2 [[13]]

[[14]]Anxiety Disorders Association of America. (2008). Anxiety Disorders in Older Adults. Retrieved November 21, 2008 from http://www.adaa.org/GettingHelp/AnxietyDisordersinOlderAdults.asp ¶3 [[14]]

[[15]]Sampson, Stephanie. (2006, July 18). New Thinking on Anxiety and Aging: Anxiety Disorders Common in the Elderly. Retrieved November 21, 2008 from Anxiety Disorders Association of America:  http://www.adaa.org/aboutADAA/newsletter/anxietyandaging.htm ¶7[[15]]

[[16]]Calleo, Stanley. ¶7 [[16]]

[[17]]Anxiety Disorders Association of America. ¶2 [[17]]

[[18]]Calleo, Stanley. ¶7 [[18]]

[[19]]Cassidy, Rector. p152 ¶1 [[19]]

[[20]]Older Americans Substance Abuse & Mental Health Technical Assistance Center. (2008). Depression and Anxiety Prevention for Older Adults. Retrieved November 21, 2008 from Substance Abuse and Mental Health Services Administration (PDF): http://www.samhsa.gov/OlderAdultsTAC/docs/Depression_Booklet.pdf ¶2 [[20]]

[[21]]Fitzwater, Evelyn. (2008, February 26). Older Adults and Mental Health: Part 2: Anxiety Disorder. Retrieved November 21, 2008 from NetWellness: http://www.netwellness.org/healthtopics/aging/anxietydisorder.cfm ¶4  [[21]]

[[22]]Cassidy, Rector. p150 ¶4 [[22]]

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10 Comments… add one
Tracy
Twitter:
December 1, 2008, 9:11 pm

Actually it does ring a bell for me in a couple of older people I know, I’m looking forward to reading part II to see if there is anything I could do to help.

Would a hording disorder be considered part of Obsessive Compulsive disorder (please pardon if I have the terms wrong)?

I think we expect older people to be a little “batty” and minimize their feelings. I have to admit, I’m probably just as guilty as anyone. This is something I’m becoming more aware of as my parents age and their general health declines.

Tracy’s last blog post..I am Learning the Social Web Media Networking 2.0

D December 1, 2008, 9:30 pm

I’m not surprised anxiety disorders are under-researched in older adults. Seems like anxiety itself doesn’t get as much attention, no matter what the age. Right now, a lot of media attention (and maybe research dollars?) is focused on depression and bipolar disorder. At least that’s my perception :) http://iamlivingwithanxiety.blogspot.com/

D’s last blog post..It’s hard to stop a train

Mike December 1, 2008, 10:28 pm

@Tracy, thanks for the comment!
I just posted Part 2. It’s a bit long, but I couldn’t say what was needed in fewer words.

Hoarding is related to both Obsessive-Compulsive Disorder (an Anxiety Disorder) and to Obsessive-Compulsive Personality Disorder (not an Anxiety Disorder). I have not done any research on hoarding, but I think I need to; it’s been put on my list!

I think we are just now beginning to realize how much ageism permeates our society. We all are guilty of disregarding the elderly and discounting their mental and physical complaints. I hope that will change as the Baby Boomers enter retirement age and the elderly will be much more visible.

@D You are right: Anxiety Disorders have not received the same attention, either in research or in the press, as have depression or other mood disorders. This, despite its affecting many more Americans than depression or bipolar disorder. It’s my opinion that the reason for this is that everybody has anxieties, and people think those with Anxieties are just the same except more so! Incidentally, I wrote a post about this, which also explains why I capitalize Anxiety (as in Disorder), and not anxiety (as in what everybody has). It’s titled, Anxiety and anxiety: What’s the difference?

Tracy
Twitter:
December 1, 2008, 10:36 pm

@Mike, thanks, I had no idea that there was both an Obsessive Compulsive Disorder and Personality Disorder. What a wealth of information you are! I am wondering about a neighbor of ours, we’re new to the street so I don’t know her well, but from what I can see from the street her porch, carport and van are all completely filled with assorted junk. It worries me because she has limited mobility and I have no idea how to approach her to see if she needs help without insulting her. I think I’m going to keep developing a friendship and look for an opening.

Tracy’s last blog post..I am Learning the Social Web Media Networking 2.0

Kim Woodbridge
Twitter:
December 1, 2008, 10:55 pm

Oh no. I accidentally moved away from the page and lost my comment. What was I thinking …

I would think a loss in physical ability would strongly contribute to anxiety in the elderly – I know I already worry about it a little.

I am cynical about things improving as our population grows older. With such a large elderly population it seems that there may be many more pressing concerns.

@Tracy – You sound like such a kind person. The fact that you have noticed this woman and are concerned about her says a lot about your character :-)

Kim Woodbridge’s last blog post..(Anti) Social-Lists 11/30/08

Mike December 2, 2008, 12:32 am

@Tracy – It seems to be the best idea to develop a friendship. Older people are very jealous of their independence, and if the neighbor even suspects that you are trying to take that away, she may shut you off. As you get to know her, you might meet some relatives that you could talk to, too. Anyway, good for you for being concerned and proactive!

@Kim – I’m already experiencing some loss of physical abilities and it is distressing. I have to fight to maintain a good attitude about it all so that I can keep Anxiety at bay.

I’m ever the optimist, and I hope that the attitudes of people toward older adults will improve with greater exposure to them. Like you say, there are a lot of pressing concerns, but the elderly are a part of those concerns in that so many of them are in poverty, have inadequate health care because of stupid Medicare rules, and face decreased buying power from their savings and investments.

D December 2, 2008, 9:22 pm

Mike, *great* point about “anxiety” vs. “Anxiety.” You are right on the money! We really need new terminology to describe clinical anxiety problems—or at least a really good public education campaign.

D’s last blog post..Just do it

Mike December 2, 2008, 10:28 pm

D,
Unfortunately, I think that the word and concept of “anxiety” is deeply embedded into our culture. It will take education to set things straight, but there’s not much of a movement in the US to do it. Wish I could sound a bit more hopeful….

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