Anxiety Disorders affect over 18 percent of people over the age of 60. As many as 7 percent of this age group have Generalized Anxiety Disorder (GAD), a disorder characterized by uncontrollable worries about everyday things.
Despite its prevalence, Anxiety Disorders remain one of the most undiagnosed and undertreated conditions in this age group. This is due to the failure of the current model of the primary care physician as gatekeeper model.
Eric J. Lenze, M.D., assistant professor of psychiatry, University of Pittsburgh School of Medicine, says,
Studies have shown that generalized anxiety disorder is more common in the elderly … than depression, which affects about 3 percent of seniors. Surprisingly, there is little research that has been done on this disorder in the elderly.
Due to the lack of evidence, doctors often think that this disorder is rare in the elderly or that it is a normal part of aging, so they don’t diagnose or treat anxiety in their older patients, when, in fact, anxiety is quite common in the elderly and can have a serious impact on quality of life.
Baby Boomers now reaching age 60
80 Million Baby Boomers!
With the first of the 80 million “baby boomers” reaching 60 in 2006, researchers are seeing a greater need to focus attention on disorders commonly experienced by people age 60 and older. Dr. Lenze says,
Anxiety in people over age 60 might have some similarities to anxiety in those younger, but it also has marked differences. We can’t just assume that we can treat the two age groups the same. We are decades behind where we need to be in terms of research and treatments for anxiety in this older age group.
It would appear that the medical and mental health professions let the aging of the baby boomer generation slip up on them!
What are the most common Anxiety Disorders in Elders?
14.5 million Baby Boomers have an Anxiety Disorder
Anxiety Disorders are the most common mental illness in the US, affecting 18.1 percent of the population. Of the 80 million baby boomers, 14.5 million of them have or will have some variety of Anxiety Disorder, according to the National Institute of Mental Health.
People with Anxiety Disorders are 3 to 5 times more likely to go to the doctor to seek relief for Anxiety symptoms that mimic physical illnesses than those in the unaffected population. The Anxiety Disorders Association of America says that this accounts for 16 percent of the country’s entire mental health bill.
Anxiety Disorders commonly found among those 60 years and older are:
- Agoraphobia – About .8 percent of elders over 60 have or will develop Agoraphobia, in which the person becomes afraid of being in any place or situation where escape might be difficult or help unavailable in the event of a panic attack.
- Generalized Anxiety Disorder (GAD) – 7 percent of those 60 and older are diagnosable as having GAD, as opposed to 3.1 percent of the general population, more than double. Women are twice as likely to be affected as men. GAD is very likely to be present along with other disorders, such as depression.
- Obsessive-Compulsive Disorder (OCD) – About 1 percent of those over 60 years are diagnosable as having OCD. It is equally common among men and women. One third of affected adults first experience symptoms in childhood, and the disorder rarely begins after age 60.
- Panic Disorder – About 2.7 percent of baby boomers are diagnosable as having Panic Disorder. Women are twice as likely as men to be affected. About one in three people with Panic Disorder develop Agoraphobia. It has a very high comorbidity (two chronic diseases simultaneously) rate with depression.
- Post Traumatic Stress Disorder (PTSD) – About 3.5 percent of those 60 and over will have PTSD. Of the baby boomers who served in Viet Nam, 19 percent have experienced PTSD at some point.
- Social Anxiety Disorder (or Social Phobia – SAD) – About 6.8 percent of elders are affected by SAD. Since it typically begins in childhood or adolescence, elders with SAD will already have been diagnosable.
- Specific Phobias – About 8.7 percent of elders have or will have a Specific Phobia. Women are twice as likely to be affected as men.
Primary care physicians are the key element in Elder care
Primary care doctors are “gatekeepers”
Medicare and most managed health insurance providers use a “gatekeeper” system wherein the primary care physician is the first contact for the patient with a complaint. That means that an elder complaining of Anxiety-based symptoms will see her primary care physician first, and if necessary, be referred to specialists.
Primary care physicians have been well-trained to test for and spot depression among their patients, but not so for Anxiety Disorders. Drs. Wayne Katon and Peter Roy-Byrne of the Annals of Internal Medicine say in an editorial,
Anxiety disorders have been the neglected stepchild of primary care-based mental health care. Compared with the extensive research in primary care on the adverse effects of depression … far less research has been completed on anxiety disorders. Yet, the National Comorbidity Survey has shown that anxiety disorders are the most frequent disorders in the general population and are associated with substantial social and vocational impairment. Primary care patients with anxiety disorders are high users of primary care services and have many medically unexplained symptoms (that is, chest pain and rapid heart rate), clinically significant decrements in function, and high medical costs.
Accurate recognition of anxiety disorders in primary care is the first step in providing effective treatment and potentially preventing development of major depression and social and vocational impairment.
More effective screening tools for Anxiety Disorders are being developed, such as the GAD-7 test detailed in the article, “Anxiety Disorders Common But Often Undiagnosed.” But many changes need to be made in the system for it to become more effective.
Primary care treatment for Anxiety Disorders has failed
Serious failure in the management of Anxiety Disorders
Screening for Anxiety Disorders is a necessary first step in the treatment of Anxiety. But the evidence tells us that making a diagnosis is not sufficient to improve the quality of mental health care and outcomes among primary care patients with Anxiety Disorders. Drs. Katon and Roy-Byrne say,
Studies have shown that primary care patients who are accurately diagnosed with anxiety disorders have important gaps in the mental health care that they receive, including poor adherence to psychoactive medications, poor follow-up by primary care physicians, and infrequent exposure to … psychotherapies (such as cognitive–behavioral therapy).
These findings, together with the high prevalence of anxiety disorders, indicate a serious failure in the management of anxiety in the primary care setting.
Collaborative care is the most effective model
Collaborative care works
It has been found that collaborative care models are an important element in improving the quality of mental health care. They use allied health professionals, such as nurses, to support primary care physicians. Psychiatrists and psychotherapists may also be on the team.
A care manager, such as a nurse, provides patient education, closely follows patients, tracks adverse effects of care, monitors adherence to care programs, monitors progress, and facilitates return visits with the primary care physician if progress is not being made. In the most successful collaborative care programs, a psychiatrist supervises the care manager and recommends medication adjustments.
Drs. Katon and Roy-Byrne note,
A potentially key element of the most successful collaborative care programs is patient self-activation, which may be particularly important for patients with anxiety because they actively avoid specific anxiety-provoking situations and behaviors. Self-activation is an important element in overcoming avoidance, which is necessary for anxiety syndromes to fully remit. [Studies have proven that] this aspect of anxiety disorders also suggests that cognitive-behavioral treatments may be particularly important for patients with anxiety.
What do you think?
Health care is not ready for the Boomers
It is obvious that a significant proportion of the US population is reaching 60 years old. But medical and mental health are ill-prepared for the sudden millions of patients over 60. There are fewer gerontologists than in past years, and few being trained. The psychiatrists and psychologists who are specially trained in gerontology are scarce as hen’s teeth. Even the system of primary care physicians must be completely remade to take care of the flood of new elders.
- Have you had an experience with a primary care physician and a mental disorder? Please tell your story!
- Do you think that the current system of primary care physicians is adequate, or do we need to scrap it and start over?
As always, your comments are welcome!
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Resources used in this post:
Anxiety Disorders Association of America. (2008). Statistics and Facts About Anxiety Disorders. Retrieved August 28, 2008 from Anxiety Disorders Association of America Web site: http://adaa.org/AboutADAA/PressRoom/Stats&Facts.asp
Katon, Wayne; Roy-Byrne, Peter. (2007, March 6). Anxiety Disorders: Efficient Screening Is the First Step in Improving Outcomes. Retrieved August 28, 2008 from Annals of Internal Medicine Web site: http://www.annals.org/cgi/content/full/146/5/390
National Institute of Mental Health. (2008, June 26). The Numbers Count: Mental Disorders in America. Retrieved August 28, 2008 from National Institute of Mental Health Web site: http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america.shtml
Rossi, Lisa. (2006, May 20). Anxiety common in elderly, yet often undiagnosed and undertreated. Retrieved August 28, 2008 from University of Pittsburgh Medical Center via EurekAlert Web site: http://www.eurekalert.org/pub_releases/2006-05/uopm-aci051706.php