Zvi D. Gellis, PhD, University of Pennsylvania
Stanley G. McCracken, PhD, University of Chicago
Epidemiological evidence suggests that anxiety is a common and major problem in later life, yet it has received less attention than depressive disorders have. Anxiety disorders are often associated with common age-related medical and chronic conditions such as asthma, thyroid disease, coronary artery disease, dementia, and sensory loss (Diala & Muntaner, 2003).
Anxiety in later life has been identified as a risk factor for greater disability among older adults in general and has also been associated with less successful recruitment into and outcomes of geriatric rehabilitation services (Bowling, Farquhart, & Grundy, 1996). Researchers and practitioners are beginning to recognize that aging and anxiety are not mutually exclusive; anxiety is as common in the old as in the young, although how and when it appears is distinctly different in older adults. Additionally, further effectiveness research on evidence-based treatments for late life anxiety is needed (Mitte, 2005).
Recognizing anxiety and anxiety disorders in an older person poses several challenges. Aging brings with it an increased risk for certain medical conditions; a number of realistic concerns about physical problems, life situations, and functioning; and a high use of prescription medications. As a result, separating a medical condition from physical symptoms of an anxiety disorder is complicated in the older adult. Diagnosing anxiety in individuals 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 depending on the person's situation.
Although anxiety disorders, like most psychiatric conditions, may be less common among older adults than among younger people, epidemiological evidence suggests that anxiety is a major problem in late life (Salzman & Lebowitz, 1991; U.S. Department of Health & Human Services, 1999). Anxiety disorders overall appear to be the most common class of psychiatric disorders among older people, more prevalent than depression or severe cognitive impairment (Beekman et al., 1998; Kessler et al., 2005; Regier et al., 1988).
One study involving interviews with nearly 6000 people nationwide reported a lifetime rate of 15.3% for DSM-IV-diagnosed anxiety disorders in respondents over age 60 (Kessler et al., 2005). Myers and colleagues (1984) report a 6-month prevalence of anxiety disorders in late life ranging from 6.6% to 14.9% across three Epidemiologic Catchment Area (ECA) sites.
Phobias and GADs account for most anxiety disorders in late life (Beekman, van Balkom, Deeg, van Dyck, & van Tilburg, 2000; LeRoux, Gatz, & Wetherell, 2005). Among people 55 years of age and older, Douchet, LaDouceur, Freeston, and Dugas (1998) found that 12.8% meet criteria for GAD. By comparison, ECA prevalence rates for older adults are 1.8% for major depression, 2.8% for dysthymia, and 4.9% for severe cognitive impairment (Blazer, 1997; Regier et al., 1988).
It is possible that the prevalence of anxiety is higher in primary care settings than in the community at large. Krasucki, Howard, and Mann (1999) have found that, in primary care settings, 30% of older adults present with generalized anxiety symptoms. Because evidence suggests that only approximately one third of such cases are detected in primary care (e.g., Kessler, Lloyd, Lewis, & Gray, 1999), these data likely represent a substantial underestimate of the prevalence of anxiety in that setting. Furthermore, Levy, Conway, Brommelhoff, and Merikengas (2003) found that, compared to younger adults, older adults tend to minimize and underreport their anxiety symptoms. Thus the number of older adults who experience anxiety may be underestimated (Levy et al., 2003).
Clinically significant anxiety, including symptoms that do not meet criteria for a specific disorder, is common among older adults, and the prevalence may be as high as 20-29% (Davis, Moye, & Karel, 2002; Lenze et al., 2005).
There is also controversy over whether the prevalence of anxiety has been accurately determined in older adults, because DSM-IV criteria may not fit well with this population, anxiety symptoms may be expressed as somatic features or behavior changes (e.g., aggression, assaultive behaviors), and the clinical presentation of anxiety in late life may be more likely to include depressive symptoms (Beck & Averill, 2004; Diefenbach & Goethe, 2006; Fuentes & Cox, 1997; Kim, Braun, & Kunik, 2001; Palmer, Jeste, & Sheikh, 1997).
Studies have found an association between anxiety and medical illnesses such as diabetes (Blazer, 2003), dementia (Wrag & Jeste, 1989), coronary heart disease (Artero, Astruc, Courtet, & Ritchie, 2006; Kuzbansky, Cole, Kawachi, Vokonas, & Sparrow, 2006), cancer (Deimling, Bowman, Sterns, Wagner, & Kahana, 2006; Ostir & Goodwin, 2006), chronic obstructive pulmonary disease (Karajgi, Rifkin, Doddi, & Kolli, 1990), and Parkinson’s disease (Stein, Heuser, Juncos, & Uhde, 1990).
As with young adults, anxiety in older adults has been found to often co-occur with depression (Beck & Averill, 2004; Beekman et al., 1998; Blazer, 1997). Community survey research has revealed that up to 50% of older adults with major depression had a comorbid anxiety disorder, and 25% of older adults with anxiety also had major depression (Beekman et al., 2000; Blazer, 2003; Jeste, Hays, & Steffens, 2006). Finally, approximately 20% of older adults with bipolar disorder reported having GAD at some point (Goldstein, Hermann, & Shulman, 2006).
Comorbid anxiety in late-life depression is associated with poor treatment response and increased likelihood of dropout (Lenze et al., 2003). Also, older people with anxious depression report increased suicidality and reduced psychosocial supports (Jeste et al., 2006).
Anxiety symptoms have been found to lead to depressive symptoms (Wetherell, Gatz, & Pederson, 2001).
Hypertension, hypoglycemia, and coronary heart disease can be worsened through chronic stress and anxiety (Hersen & Van Hasselt, 1992). Compared with men reporting no symptoms of anxiety, men in the Normative Aging Study reporting two or more anxiety symptoms had elevated risk of fatal coronary heart disease (Kawachi, Sparrow, Vokonas, & Weiss, 1994). Higher levels of anxiety have been associated with greater use of pain-relieving medications and more postoperative disability days for surgical patients (Taenzer, Melzack, & Jeans, 1986). Anxiety was also related to pain in a sample of nursing home residents (Casten, Parmelee, Kleban, Lawton, & Katz, 1995).
Among older adults, anxiety symptoms and disorders are associated with increased fatigue, high levels of chronic physical illness, increased disability, lower levels of well-being, substandard life satisfaction, and inappropriate use of medical services (Gellis, 2006).
(Martin, Bishop, Poon, & Johnson, 2006; Brenes et al., 2005; de Beurs, et al., 1999; Hunt, Issakidis, & Andrews, 2002; Jones, Ames, Jeffries, Scarinci, & Brantley, 2001; Wetherell et al., 2004; Wittchen, Carter, Pfister, Montgomery, & Kessler, 2000). Furthermore, a sample of older adults with GAD reported impairments on QOL measures that were worse than impairments reported by comparable individuals who had serious medical conditions such as myocardial infarction or type II diabetes and comparable to individuals with major depression (Wetherell et al., 2004).
Older adults with anxiety disorders are less likely than older adults with depression, dementia, or any other mental disorder to receive treatment from a mental health specialist (Ettner & Hermann, 1997). Levy et al. (2003) found that, compared to younger adults, older adults tend to minimize and underreport their anxiety symptoms.
Data from the ECA study suggest that benzodiazepine use among the elderly is approximately 14%, higher than the rate for younger adults (Swartz et al., 1991). A community survey of older adults in southern California showed that 20% had used benzodiazepines at least twice in the previous 12 months; these individuals were more than twice as likely as nonusers to take 10 or more drugs (Mayer-Oakes et al., 1993). Benzodiazepine users are also more likely than nonusers to experience accidents requiring medical attention, due to increased risk of falls, hip fractures, and automobile accidents (Tamblyn, Abrahamowicz, du Berger, McLeod, & Bartlett, G, 2005). Older patients taking benzodiazepines are also more likely to develop disabilities in both mobility and ADLs (Gray et al., 2006). Benzodiazepines can impair memory and other cognitive functions (Wengel, Burke, Ranno, & Roccaforte, 1993). These medications can also cause tolerance and withdrawal, interactions with other drugs, and toxicity (Krasucki et al., 1999; Salzman & Lebowitz, 1991).
Although safer medications than benzodiazepines, particularly SSRIs, are often used to treat geriatric anxiety, they can cause unpleasant side effects, and some older people prefer not to take them. Furthermore, SSRIs have not completely replaced benzodiazepines as a treatment for anxiety in older people (Keene, Eaddy, Nelson, & Sarnes, 2005).
Both monoamine oxidase inhibitors and tricyclic antidepressants have been demonstrated to be effective in treating anxiety disorders, such as panic disorder and obsessive compulsive disorder. Due to the discomfort and dangerousness of their side effect profile, they currently are used less frequently than newer medications such as SSRI’s (Kelsey, Newport, & Nemeroff, 2006).
Wetherell and colleagues (2005) reviewed the literature and reported that progressive muscle relaxation, CBT, and even supportive therapy have empirical support documenting their efficacy for treating geriatric anxiety. However, the authors report that, when compared to waitlist and supportive control conditions, the psychological treatments with the greatest effect sizes (.20 or greater) are relaxation training (for anxiety symptoms) and CBT (for anxiety disorders).
In recent years, CBT has been shown to be superior to waitlist conditions, medication management-only conditions, supportive control conditions (e.g., supportive counseling, minimal contact, discussion group), and usual primary care (Barrowclough et al., 2001; Gorenstein et al., 2005; Mohlman et al., 2003; Stanley, Beck, et al., 2003; Stanley, Hopko, et al., 2003; Wetherell, Gatz, & Craske, 2003). In some of the other studies, compared to waitlist or supportive control conditions, CBT also provided greater reductions in comorbid depression, as well as improvements in QOL (Barrowclough et al., 2001; Stanley, Beck, et al., 2003; Stanley, Hopko, et al., 2003; Wetherell et al., 2003). However, in a recent study comparing CBT plus medication management with medication management alone, the combined approach was not found to be superior in reducing anxiety, worry, and total distress (Gorenstein et al., 2005). These mixed results warrant further understanding and research as to the most effective treatment approaches for late life anxiety
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