Treating Older Adults for Anxiety

In older adults, anxiety can lead to increased disability, reduced functional status, more health care costs, and increased mortality, said Melinda Stanley, Ph.D., a professor and head of the Division of Psychology in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine and Houston VA Health Services Research.

Prevalence rates for anxiety disorders and generalized anxiety disorder in particular may nearly double among patients with chronic illness, she said.

“When evaluating these patients, clinicians must understand how they experience or express anxiety,” said Stanley.

Older patients show a lower correlation between affect and arousal than younger patients and are more apt to speak of somatic symptoms like gastrointestinal complaints, dizziness, or back pain, for instance. They may avoid psychological language and say they don’t “worry” but are “concerned” about their condition, she said. They may have memory difficulties and simply fail to remember symptoms they have experienced before coming to the clinic.

Treatment should begin with a medical evaluation and tests for cognitive impairment and depression, said Stanley. Patients may need education about anxiety and its symptoms, and the language used should be easy to understand.

She has found that most older patients prefer nondrug treatments, possibly because they may be on a number of other medications already, said Stanley. Psychiatrists and therapists of older patients must also work more closely with their patients’ other health care professionals and family members to coordinate care, she said.

Antidepressants have a 65 percent response rate among older adults, she said. While benzodiazepines perform better than placebo, cognitive side effects may rule them out as a first-choice treatment.

A meta-analysis of five trials of cognitive-behavioral therapy (CBT) indicated that CBT produced only moderate to small effects comparing group versus individual therapy, she said. Furthermore, the trials had only a limited representation of older adults.

There have been only a few, small, uncontrolled trials for mixed late-life anxiety disorders such as generalized anxiety disorder, panic disorder, or obsessive-compulsive disorder, and the trials had high attrition rates. Many trials included only relatively young “older” patients (65 to 68 years) and so do not convey much information about older cohorts.

Ongoing research is investigating links between anxiety and dementia, executive dysfunction, hoarding, and fear of falling. Trials are also under way of different treatment modalities (exposure for generalized anxiety disorder, combined CBT and medication), settings (home health care), and delivery options (telephone-based treatment).

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Aaron Levin
Psychiatric News April 2, 2010   vol. 45 no. 7 13-23
American Psychiatric Association