Sleeping Geriatric Giant: Anxiety Disorders in Older Adults, Part 2

by Mike Nichols – Posted in: Anxiety

The diagnosis of Anxiety Disorders in older adults is made all the more difficult because the stigma of mental illness makes it hard for elders to talk about them.

And it’s not helped along by the fact that, until recently, Anxiety Disorders in older adults was little-studied and were treated with dismissal and veiled ageism. However, research is accelerating in the treatment of older adults, and there are some very effective therapies becoming available.

Still, diagnosis of Anxiety Disorders in older adults is difficult at best, because it takes a great deal of sensitivity and experience to ask the right questions. Family and friends are very important in the diagnosis, since they can see the changes in moods, behavior, and habits that a physician cannot see.

This post is the second in a two-part series on the Anxiety Disorders in older adults. Yesterday’s post addressed how many older adults have Anxiety Disorder, how it is strongly linked with depression, and the risk factors. This post covers the following topics:

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?

Why are Anxiety Disorders so hard to diagnose in older adults?

Mental Illness in elders poorly understood

Mental illness in the elderly remains a poorly understood subject, and researchers are just now beginning to focus on Anxiety Disorders in older adults. Even so, some recent studies have been flawed, for example those studies of the Anxiety Disorders that have excluded Generalized Anxiety Disorder, one of the most prevalent Anxiety Disorders in older adults. The health questionnaires used to assess Anxiety are designed for younger adults, and include a combination of physical and psychological symptoms that do not measure Anxiety in older adults adequately.{{1}}

This leaves physicians and researchers very little to go on when trying to diagnose older patients. Murray Stein, M.D. and Professor in Residence in the Department of Psychiatry of the University of California at San Diego says,{{2}}

We know that depression presents differently in older people — for example, older depressed patients are more likely to complain of physical rather than psychological symptoms — and these differences may also be true of anxiety in the aged, but we just don’t have enough research yet to be sure,” says Stein.

A major barrier to the diagnosis of Anxiety Disorders in older adults is the fact that they are likely to attribute the symptoms to physical sources, such as muscle tension, stomach upset, or fatigue. And because older people tend to attach a negative stigma to mental health issues, they often describe anxieties as problems with their “nerves” and being “nervous and upset” about things.{{3}} Mezy and Berkman say,{{4}}

Older adults are not only more likely to report physical symptoms but also more likely than younger adults to attribute anxiety symptoms to medical causes and to experience medical problems with overlapping symptoms. Patients may be reluctant to report anxious feelings but readily admit to problems with sleep, concentration, fatigue, or aches and pains.

When Anxiety Disorders coexist with other psychiatric illnesses, such as depression, the diagnosis of disorders is greatly complicated.{{5}} It is often very difficult to distinguish between depression and anxiety in the older patient. Murray Stein says,{{6}}

With aging often come aches, pains, distractability, embarassment about conditions such as incontinence, or just fear of that next heart attack. However, an anxiety disorder should be considered in any older patient with depressive symptoms or with physical symptoms that are not explained by a physical problem, such as chest pain, palpitations, shortness of breath, diarrhea or sleep problems.

Stein adds that physicians should suspect anxiety as the cause of physical symptoms if the symptoms have lasted for two years or more with little change.

Overview of treatment of Anxiety Disorders in older adults

Accepting that one has a problem is the first step

The first step in effective treatment of Anxiety Disorders for any age group is acknowledging and accepting that one has a problem. As seen in the previous section, older people many times will not admit to having psychological problems, or they will attribute them to physical causes. Glenn Brynnes, Ph.D., M.D., a psychiatrist and co-director of North County Psychiatric Associates in Baltimore County, Maryland, states:{{7}}

Sometimes, an older person is more willing to admit they have a physical problem — such as chest pain or sleep problems — than a psychological one. He or she may be searching for control at a time when control over many issues is being lost. Getting them to realize that the changes in their lives caused by excessive fear and worry are absolutely not something they have to accept is a key part of treatment.

Older adults receive most of their mental health services from their primary care physicians. Many older people feel more comfortable opening up to a doctor with whom they already have a relationship. Also, if they already trust their primary care physician, the chances are increased that they will go along with treatment or a referral to a mental health professional.{{8}}

However, primary care physicians overwhelmingly prescribe medications rather than psychosocial treatments such as therapy. In primary care, 50 percent of older patients with Anxiety Disorders are prescribed anti-anxiety medications or antidepressants. Only 14 percent of older adults with Anxiety Disorders receive services from mental health professionals, including psychiatric medication management or counseling.{{9}}

It has been found that success in treating Anxiety Disorders in the older patient depends, in part, on a partnership between the patient, the family, and the doctor. Everyone needs to agree on what the problem is and make a commitment to stick with treatment until the patient can return to normal functioning. Family members may need to advocate for the older person, ensuring that issues encountered during treatment, such as drug side effects, are dealt with promptly.{{10}}

Medications for Anxiety Disorders in older adults

Research on late life Anxiety Disorders is sparse

Research on pharmacological treatment of Anxiety Disorders in late life is sparse and guidelines are generally not based on controlled trials of older adults, but on extrapolation from research with younger age groups.{{11}}{{12}} However, it has been found that available medications are reasonably effective, though with important caveats. Given the higher average treatment effects of medications, and the resistance of both physicians and patients to therapy or counseling, they may be the first choice of treatment as long as medical conditions and patients’ preferences do not preclude this form of treatment.{{13}}

The general principle for the use of medications with older adults is to start low and go slow, but also aim high and treat long. This principle is especially useful in the treatment of older persons with Anxiety Disorders,who worry about taking medications, are acutely aware of and sensitive to side effects, and have high dropout rates.{{14}}

The anxiolytic (anti-anxiety) drugs, primarily benzodiazepines such as Ativan, Klonopin, Halcion, Xanax and Valium and the generic Alprazolam, are prescribed with hesitancy by most primary care physicians. They can be addictive, and their side effects may exacerbate existing balance problems and dizziness, causing falls in the older patient. If prescribed at all, they are given for short periods of time only.

The selective serotonin reuptake inhibitors (SSRI’s), like Celexa, Lexapro, Paxil, Prozac, and Zoloft, are the preferred medication for most Anxiety Disorders. Drug therapy with the SSRI’s may last a year or longer. Murray Stein says:{{15}}

SSRI’s can treat the anxiety and depression that often coexist in the anxious older patient and are generally less likely to result in over-sedation, cognitive impairment, or physical dependence compared to other drugs used for anxiety.

Despite promising results for the use of antidepressants, physicians should be aware of increased risk factors for older adults, including the potential for drug-drug interactions in medically ill patients. Many older people take a number of drugs prescribed by several doctors, and what might be the normal side effect of one medication may be a serious side effect of another. New medications under consideration should take into account all prescription and over-the-counter drugs a patient is taking.

Non-adherence to psychiatric medication is another important issue because older adults may forget to take medications, may be confused about dosages, may overuse prescribed medications, or may supplement them with over-the-counter medications. The reasons for non-adherence may include adverse side effects, cost considerations, confusion, or insufficient knowledge about proper use.{{16}} Physicians should take special care that the older patient understands how to take the medication. They should also be sensitive to the cost of the drug, and aid in the patient’s participation in low- or no-cost drug programs if necessary.

Therapy for Anxiety Disorders in older adults

No therapy for elders: Ageism?

Historically, older adults have not been offered psychotherapy, possibly due to ageism.{{18}} However, a growing body of research supports the use of therapy, particularly Cognitive-behavioral Therapy (CBT), as an effective means to treat older patients. At least four academic clinical trials have demonstrated the utility of CBT for older adults with Generalized Anxiety Disorder (GAD). More trials with CBT for other Anxiety Disorders, such as Panic Disorder and Obsessive-Compulsive Disorder, are underway. There is also research into developing a new ways to use CBT with older patients.{{19}}

Cognitive Behavioral Therapy is being used increasingly to reduce Anxiety in older adults. CBT can take up to several months, but has the advantage that it has no side effects. CBT may involve:{{20}}{{21}}{{22}}

Relaxation training, consisting of some combination of progressive muscle relaxation, deep breathing, meditation, and education about tension and stress
Cognitive restructuring (replacing Anxiety-producing thoughts with more realistic, less catastrophic ones)
Exposure therapy (systematic encounters with feared objects or situations).

Recent developments of “enhanced” models of CBT for older adults have been shown to be more effective than standard CBT in an individual format and also a group format.{{23}} They have been modified to better meet the needs of older adults, including using large print and mnemonics to reinforce core concepts, Telephone sessions have been tried as a way to provide care for older adults who have difficulty with mobility or transportation.{{24}}

Asking the right questions to diagnose Anxiety

Right answers require right questions

Older people are often reluctant to report or discuss psychiatric problems. Asking the same questions you might ask a younger person will get you either no answers or a rebuff. To help identify Anxiety in patients and discover the pattern of the physical symptoms, you may find it easier to phrase questions similar to these:{{25}}

To identify anxiety:

Have you been concerned about or fretting 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?

Note that these questions do not address the psychological issues directly, but ask about things that the older adult may report to their doctor. Cassidy and Rector have developed a battery of questions that are also useful for talking to older adults.{{26}}

Worried about an aging parent or loved one?

Behavior, habit, mood changes cause for concern

When your aging parent’s or loved one’s behavior changes, it can be a cause of concern. In particular, if their mood changes, it might be a signal that they are having problems with Anxiety Disorders or depression. Glenn Brynes says:{{27}}

Talking to your parent or loved one about any changes in their lives is still one of the best ways to find out if there is a problem. You aren’t trying to diagnose anything, just determine if help is needed. In most cases, if you think there’s a problem, there probably is, even if your loved one may not admit it just now.

Ask your loved one about any changes you notice in the following:{{28}}

Daily routines and activities: Are they refusing to do previously routine activities or avoiding social situations they used to enjoy?
Worries: Do they seem to have more worries than before and do those worries seem out of proportion to reality (such as a real threat to their safety)?
Medication: Have they recently started taking another medicine? Are they using more of a particular medication than before? Are they also using over-the-counter medications? Medication side effects (such as breathing problems, irregular heartbeat, or tremors) can simulate symptoms of Anxiety. Also, 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.

Conclusion

The sleeping geriatric giant

Anxiety Disorders are the “sleeping geriatric giant.” They have been ignored or set aside as negligible until recently. However, it has been found recently that up to 11 percent of the older adult population aged 55 years and older will be affected by Anxiety Disorders in their lifetimes. And what’s more, 17 percent of older men and 21 percent of older women will have Anxiety symptoms that do not meet the criteria for a disorder.{{29}}{{30}}

Research has been and still is relatively slow on Anxiety Disorders in older adults. But what has emerged is:

The tests and questionnaires used to assess the mood of older adults are inadequate, and do not take into account the effects of aging.
Much of what doctors have to go on is outdated or based on research done on younger subjects.
Most older adults use their primary care physician for mental health problems. These doctors overwhelmingly prescribe drugs rather than therapy, which can be as effective or more effective in relieving Anxiety symptoms as medications.
Treatment with medications is based on trials with younger adults, but nevertheless is effective in the elderly, though with important differences.
Research has found that psychotherapy can be effective with older adults, especially Cognitive Behavioral Therapy. New techniques in CBT are being developed to target the special needs of older adults.

Despite the tentative nature of treatment at the time, enough is known so that older adults suffering from Anxiety Disorders can be diagnosed and treated effectively. Although primary care physicians may try to treat Anxiety Disorders solely with drugs, referrals to psychotherapy are available if one insists. And psychotherapy, especially Cognitive Behavioral Therapy, seems to be very effective in relieving the symptoms of Anxiety Disorders in older adults.

Please read the first post in this series!

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?

What do you think?

I suspect my mother, who passed away some years ago, was suffering from Anxiety Disorders and depression in her latter years due to changes in her behavior and the unguarded remarks she made. But she never would have reported her concerns to her physician, because of the stigma of mental illness.

It is a shame that this stigma keeps so many people — particularly older people — from getting the care that is available. The Anxiety Disorder Association of America (ADAA) and the National Alliance on Mental Illness (NAMI), in particular are fighting the stigma of mental illness. I urge you to look at their websites to see what they are doing. Just click on the badges in the rightmost sidebar!

Do you have any experience with Anxiety Disorders in older adults?
How do you think ageism has affected the lives of older adults, especially as it concerns mental health?
If you are an older adult, has anything in this series rung a bell?

As always, your comments are welcome!

The sleeping geriatric giant

%RELATEDPOSTS%

[[1]]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 ¶6[[1]]

[[2]]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 ¶19[[2]]

[[3]]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 ¶7 [[3]]

[[4]]Mezey, Mathy; Berkman, Barbara. The Encyclopedia of Elder Care. New York: Springer Publishing Company. 2001. p. 62 ¶7, 8 [[4]]

[[5]]Lauderdale, SA; Sheikh, JI. (2003, November). Anxiety disorders in older adults. Retrieved November 21, 2008 from PubMed: http://www.ncbi.nlm.nih.gov/pubmed/15024809 ¶1 [[5]]

[[6]]Sampson, Stephanie. ¶10[[6]]

[[7]]Sampson, Stephanie. ¶8[[7]]

[[8]]Anxiety Disorders Association of America. (2008). Anxiety Disorders in Older Adults. Retrieved November 21, 2008 from http://www.adaa.org/GettingHelp/AnxietyDisordersinOlderAdults.asp ¶6 [[8]]

[[9]]Calleo, Stanley. ¶8 [[9]]

[[10]]Anxiety Disorders Association of America. ¶8 [[10]]

[[11]]Lauderdale, Sheikh. ¶1 [[11]]

[[12]]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 p153 ¶3[[12]]

[[13]]Pinquart, Martin; Duberstein, Paul. (2007, August). Treatment of Anxiety Disorders in Older Adults: A Meta-analytic Comparison of Behavioral and Pharmacological Interventions. Retrieved November 21, 2008 from American Journal of Geriatric Psychiatry: http://ajgponline.org/cgi/content/abstract/15/8/639 ¶4 [[13]]

[[14]]Cassidy, Rector. p153 ¶4 [[14]]

[[15]]Sampson, Stephanie. ¶16[[15]]

[[16]]Calleo, Stanley. ¶11 [[16]]

[[17]]Cassidy, Rector. p155 ¶1 [[17]]

[[18]]Stanley, Melinda; Diefenbach, Gretchen; Hopko, Derek. (2004, January). Cognitive Behavioral Treatment for Older Adults with Generalized Anxiety Disorder: A Therapist Manual for Primary Care Settings. Retrieved November 21, 2008 from Education Resources Information Center: http://eric.ed.gov:80/ERICWebPortal/custom/portlets/recordDetails/detailmini.jsp?_nfpb=true&_&ERICExtSearch_SearchValue_0=EJ689785&ERICExtSearch_SearchType_0=no&accno=EJ689785 ¶1[[18]]

[[19]]Anxiety Disorders Association of America. ¶7 [[19]]

[[20]]Sampson, Stephanie. ¶17[[20]]

[[21]]Meek, William. (2007, April 27). Psychological Treatments for Older Adults with Anxiety. Retrieved November 21, 2008 from: http://gad.about.com/od/researchreports/a/olderadults.htm ¶4[[21]]

[[22]]Cassidy, Rector. p155 ¶1 [[22]]

[[23]]Calleo, Stanley. ¶22 [[23]]

[[24]]Anxiety Disorders Association of America. Section 4 [[24]]

[[25]]Sampson, Stephanie. Section 7 [[25]]

[[26]]For more questions that might be appropriate, see Cassidy, Rector. p152 [[26]]

[[27]]Sampson, Stephanie. Section 8 [[27]]

[[28]]Anxiety Disorders Association of America. Section 5 [[28]]

[[29]]Calleo, Stanley. ¶1 [[29]]

[[30]]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 [[30]]