July/August 2013 Issue

Anxiety Disorders in Older Adults
By Michael B. Friedman, LMSW; Lisa Furst, LMSW, MPH; Zvi D. Gellis, PhD; and Kimberly Williams, LMSW
Social Work Today
Vol. 13 No. 4 P. 10

Anxiety disorders are the most prevalent mental health conditions, and in any given year, about 10% of adults aged 65 and older experience a diagnosable anxiety disorder (Byers, Yaffe, Covinsky, Friedman, & Bruce, 2010). Over their lifetimes, about 15% of those who survive past the age of 65 will have had an anxiety disorder (Kessler, Berglund, Demler, Jin, Merikangas, & Walters, 2005).

Until recently, research on anxiety disorders among older adults was limited by a lack of information because many of these disorders have gone undetected and untreated. However, the pace of research has been accelerating, and there are some effective interventions now available.

While the state of anxiety—an experience of tension and apprehension—is an ordinary response to a threat or danger, excessive anxiety that causes distress or interferes with daily life is not a normal part of the aging process.

In general, older adults with anxiety disorders experience more difficulties managing their day-to-day lives than older adults with normal worries, and they are at greater risk of physical illness, falls, depression, disability, premature mortality, social isolation, and placement in institutions (Wolitzky-Taylor, Castriotta, Lenze, Stanley, & Craske, 2010).

The prevalence of anxiety disorders increases among older adults who have physical illnesses, particularly those in need of home health care or who live in residential care settings such as nursing homes, assisted-living facilities, or homes for the aged (Gellis, 2009).

Many people are surprised to learn that older adults are less likely to experience anxiety disorders (or depression) than are younger adults, but people who live into old age generally have developed strengths and coping skills that enable them to experience fewer negative emotional reactions, tolerate life’s ups and downs, and deal effectively with crises such as large-scale disasters (Wolitzky-Taylor et al).

Co-Occurring Disorders
Anxiety disorders frequently co-occur with other mental health conditions, especially depression. Substance misuse or abuse likewise is common among individuals with anxiety disorders. Anxiety, alone or in combination with depression, also frequently co-occurs with physical disorders that become more prevalent with aging, such as cardiac conditions, respiratory problems, and balance problems. The co-occurrence of anxiety disorders and physical diseases considerably raises the risk of poor physical outcomes (Wolitzky-Taylor et al).

People with mild cognitive decline or dementia frequently experience anxiety and depression. Distinguishing between symptoms of anxiety and depression, such as difficulties with concentration and decision making, and cognitive decline due to dementia can be difficult (Wolitzky-Taylor et al). In fact, some researchers maintain that neuropsychiatric symptoms are inherent in dementia rather than the reflection of a separate co-occurring disorder (Lyketsos, Lopez, Jones, Fitzpatrick, Breitner, & DeKosky, 2002).

Identifying Anxiety Disorders
Anxiety disorders are not easy to identify because they often are exacerbations of normal worries or long-term personality traits. Older adults frequently experience anxiety symptoms as physical problems, such as headaches, gastrointestinal distress, and fatigue. As noted above, anxiety disorders often co-occur with other disorders that produce symptoms similar to anxiety. These issues pose significant detection and diagnostic challenges.

The major distinctions between anxiety disorders and normal worries are perceived distress and ability to function. Although serious anxiety disorders usually interfere with functioning in some way, mild or moderate anxiety may not be apparent unless professionals probe for information about aspects of life that are causing concern. Indications of pathological anxiety are the painfulness and/or inconsistency of the fear and the perception of reality related to it on the one hand and the actual reality on the other. In addition, it’s important to ask about the following:

• Physical complaints: Since older adults are more likely to report physical causes of anxiety symptoms and experience medical conditions with overlapping symptoms, asking about physical complaints such as chest pain and shortness of breath is critical.

• Eating: People who are anxious may overeat to calm themselves and subsequently gain weight or they may skip meals and lose weight.

• Sleeping: People who are anxious may sleep to avoid their fears or stay awake ruminating about imagined or exaggerated dangers or trying to avoid bad dreams.

• Interests: People who are anxious tend to find fewer activities pleasurable as they become more fearful.

• Going out: Often people who are anxious stay at home to avoid their fears.

• Use of alcohol and other substances (legal or illegal): Substance use, misuse, or abuse can help people with anxiety disorders feel less frightened, though often at the cost of full function.

• Social isolation: This is a major sign of anxiety and/or depressive disorders. It does not mean living alone; it means being largely cut off from the outside world. Many people who live alone have friends, go out, and have active interests. People who are socially isolated may have lost their relationships with family and friends, do almost nothing that gives them pleasure, and may not leave their homes except for doctors’ visits or to buy groceries. Some people are isolated because of physical problems, but many people are isolated because they are too depressed or frightened to leave their homes. Frequently, they are caught in a vicious cycle. Social contact and activity would lift their spirits and calm their fears, but they are too anxious and/or depressed to do what would help them most. They then become increasingly anxious and/or depressed because of their isolation. Breaking the cycle of isolation is exceedingly difficult and often requires persistent outreach and great patience (Brennan, Vega, Garcia, Abad, & Friedman, 2005).

Supportive Interventions
For some older adults with anxiety disorders, a relationship with a caring person who directly addresses isolation and inactivity can be helpful. This can be a family member, friend, social worker at an older adult center, clergyman or chaplain, or others. Engaging people with anxiety in social, creative, or other activities they find interesting also can be helpful.

Helping older adults manage matters that may be a source of anxiety, such as dealing with health issues, financial matters, and concerns about being a burden to others, can make a big difference. In addition, spiritual experiences can benefit many older adults who believe in God or some transcendental reality. Some elders find that meditation eases their anxiety.

Psychotherapies
Such therapies include cognitive behavioral, problem solving, and interpersonal, all of which require specialized training. Of the three, problem-solving therapy can be learned most quickly.

In addition to the verbal aspects of these therapies, they often involve education and support in managing anxiety in structured ways, such as progressive muscle relaxation, sleep hygiene, and deep breathing.

Psychiatric Medications
There is a growing dispute about the use of pharmacological interventions for older adults, particularly those with chronic health conditions, because of the physical health risks associated with psychiatric medications, including antianxiety agents, antidepressants, and antipsychotics. The risks are particularly high for people taking prescription painkillers, which now are the major cause of drug overdose deaths and often are used in combination with other drugs, such as barbiturates and benzodiazepines, to treat anxiety (Centers for Disease Control and Prevention, 2011). There also are higher risks for people with dementia and perhaps those with mild cognitive impairment.

Nevertheless, psychiatric medications frequently are used to treat older adults with anxiety disorders, and they can be helpful either alone or in combination with psychotherapy. Most commonly prescribed are benzodiazepines such as alprazolam (Xanax), clonazepam (Klonopin), and lorazepam (Ativan). Buspirone is an effective treatment for generalized anxiety disorder, but there are limited data on its efficacy among older adults.

For older adults with co-occurring depression, PTSD, or social anxiety, antidepressants often are prescribed. Given elders’ health risks associated with these medications, it is preferable for them to be prescribed on a short-term basis at the lowest effective doses with careful monitoring regarding their effects on blood pressure, heart conditions, balance, etc.

*The opinions expressed in this article are the authors’ and do not necessarily reflect the opinions of the organizations for which they work.

— Michael B. Friedman, LMSW, is an adjunct associate professor at Columbia University and honorary chair of the Geriatric Mental Health Alliance in New York City.

— Lisa Furst, LMSW, MPH, is director of education for the Geriatric Mental Health Alliance and director of public education at the Center for Policy, Advocacy, and Education.

— Zvi D. Gellis, PhD, is an associate professor and director of the Center for Mental Health & Aging at the School of Social Policy & Practice at the University of Pennsylvania in Philadelphia.

— Kimberly Williams, LMSW, is director of the Geriatric Mental Health Alliance.

References
Brennan, M., Vega, M., Garcia, I., Abad, A., & Friedman, M. B. (2005). Meeting the mental health needs of elderly Latinos affected by depression: implications for outreach and service provision. Care Management Journal, 6(2), 98-106.

Byers, A. L., Yaffe, K., Covinsky, K. E., Friedman, M. B., & Bruce, M. L. (2010). High occurrence of mood and anxiety disorders among older adults. Archives of General Psychiatry, 67(5), 489-496.

Centers for Disease Control and Prevention. (2011). Vital signs: overdoses of prescription opioid pain relievers—United States 1999-2008. MMWR Morbidity and Mortality Weekly Report, 60(43), 1487-1492.

Gellis, Z. D. (2009). Evidence-based practice in older adults with mental health disorders. In: Roberts A., ed. Social Work Desk Reference. 2nd ed. (pp. 843-852) New York, NY: Oxford Press.

Kessler, R., Berglund, P., Demler, O., Jin R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Replication Survey. Archives of General Psychiatry, 62(6), 593-602.

Lyketsos, C .G., Lopez, O., Jones, B., Fitzpatrick, A. L., Breitner, J., & DeKosky S. (2002). Prevalence of neuropsychiatric symptoms in dementia and mild cognitive impairment. Journal of the American Medical Association, 288(12), 1475-1483.

Wolitzky-Taylor, K. B., Castriotta, N., Lenze, E. J., Stanley, M. A., & Craske, M. G. (2010). Anxiety disorders in older adults: A comprehensive review. Depression and Anxiety, 27, 190-211.