Diagnosing and Treating Anxiety in Older Adults
This information on anxiety is for health and mental health professionals including:
- psychologists
- psychiatrists
- psychotherapists
- physicians
- psychiatric nurses
- clinical social workers
This information is for reference only. Actual recommendations will depend on the needs of individual patients and resources available.
Prevelance
Risk Factors and Symptoms
Diagnosis
Management
Prevelance
According to Mental Health: Report of the Surgeon General, 11.4% of the population over the age of 55 suffers from an anxiety disorder in any given year. (U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999).
PTSD affects about 5.2 million adult Americans. (Narrow WE, Rae DS, Regier DA. NIMH epidemiology note: prevalence of anxiety disorders. One-year prevalence best estimates calculated from ECA and NCS data. Population estimates based on U.S. Census estimated residential population age 18 to 54 on July 1, 1998. Unpublished.)
The Epidemiologic Catchment Area Study, conducted by the National Institute of Mental Health, reported that the prevalence of panic disorder, obsessive compulsive disorder, and phobias combined ranged between 5.7% and 33% in the elderly.
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Risk Factors and Symptoms
Anxiety can be a helpful emotion. If you are in danger, the anxiety reaction alerts you, makes it easier to run for safety, and helps you remember the location and circumstances of the threat so you can avoid it in the future. Anxiety can also make you more alert for times in which you must be at your best such as a public performance or an important test. Sometimes, however, anxiety occurs without actual danger or the anxiety is excessive for the circumstances. This inappropriate or excessive anxiety an anxiety disorder––can interfere with a person s ability to function. Recognizing an anxiety disorder is the first step in managing it.
- Risk factors for anxiety
- Family history of:
- Alcohol abuse
- Anxiety disorders
- Mood disorders
- Personal history of:
- Depression
- Anxiety disorder
- Chronic medical illness, especially diabetes mellitus, mitral valve prolapse, Parkinson’s disease, Alzheimer’s disease, congestive heart failure, or hyperthyroidism
- Loss of significant person during childhood
- Cognitive impairment
- Alcohol abuse/dependence
- Social isolation
- Other factors:
- Female gender
- Exposure to traumatic event
- Symptoms of anxiety
- Excess or undue worry or fear
- Fatigue
- Disturbed sleep
- Jumpiness, jitteriness, trembling
- Muscle aches, tension
- Dizziness, lightheadedness
- Gastrointestinal upset
- Dry mouth, sensation of a lump in the throat, choking sensation
- Clammy hands, sweating
- Racing heartbeat, chest discomfort
- Shortness of breath, or the feeling of being smothered
- Numbness or tingling of hands, mouth, or feet
- Symptoms of a Panic Attack:
intense fear or discomfort in which 4 or more of the following symptoms occur abruptly and peak within 10 minutes:
- Palpitations
- Sweating
- Shaking
- Shortness of breath, feeling smothering
- Choking sensation
- Chest pain
- Nausea/GI distress
- Dizziness
- Derealization. A feeling that world feels unreal and unfamiliar
- Fear of losing control or going crazy
- Fear of dying
- Numbness/tingling of hands, mouth, and feet
- Chills, hot flashes
- Causes of symptoms
- Excessive ingestion of alcohol and/or other substances, including caffeine, stimulants, or chocolate
- Medical illness such as hyperthyroidism, hypoglycemia, mitral valve prolapse, congestive heart failure, acute bronchitis, or angina
- Side effects of prescription and over-the-counter medications such as bronchodilators and inhalers
- Withdrawal due to sudden discontinuation of a substance such as alcohol, paroxetine, or benzodiazepines (valium, xanax, tranxene, or halcyon)
- Stressful situation (e.g., loss of a loved one, traumatic incident, or major life transition such as retirement)
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Diagnosis
A definitive diagnosis of generalized anxiety disorder (GAD) is based on the following criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV):
- A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
- B. The person finds it difficult to control the worry.
- C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months):
- 1. Restlessness or feeling keyed up or on edge
- 2. Being easily fatigued
- 3. Difficulty concentrating or mind going blank
- 4. Irritability
- 5. Muscle tension
- 6. Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
Other primary anxiety disorders: DSM-IV diagnostic criteria:
- Specific phobia: Excessive fear of a specific situation or object. Exposure to the feared object/situation almost always causes anxiety. Avoidance of the feared object/situation interferes with the person s life.
- Panic disorder: Recurrent panic attacks, followed by at least 1 month of worry about having another panic attack, losing control, having a heart attack, or going crazy.
- Agoraphobia: Anxiety about being in places or situations from which escape is difficult, or where help may not be available in the event of a panic attack. More likely to occur when one is outside the home alone, in a crowd or a shopping mall, or taking public transportation. The individual may avoid places or situations that feel unsafe and he or she may not want to leave home.
- Post-traumatic stress disorder (PTSD): Reliving an event, avoiding things or situations that remind one of the event, or feeling arousal symptoms when reminded or re-exposed to reminders of a traumatic event. The event can be re-experienced through recurrent, intrusive thoughts; distressing recollections or dreams or flashbacks; psychological distress; or physical symptoms. Avoidance symptoms can include: avoidance of thoughts, feelings, activities, people, or places that remind the person of the event; trouble with memory of the event; feeling detached from others; decreased interest in activities; and restricted affect (e.g., inability to have loving feelings). Arousal symptoms are decreased sleep, irritability or angry outbursts, decreased concentration, hypervigilance, and an exaggerated startle response. Acute stress disorder is a form of PTSD that lasts from 2 days to 4 weeks. This period of anxiety occurs within 1 month of the traumatic incident.
- Obsessive-compulsive disorder (OCD): Persistent attention to inordinate fears such as worry about being dirty. This obsessive concern may lead to repetitive behaviors (compulsions) such as constant hand washing.
- Social anxiety disorder (SAD): Sweating, heart palpitations, faintness, and blushing caused by excessive anxiety about one s behavior and concern about being judged by other people. This type of anxiety can cause the individual to avoid social situations such as parties, public speaking, and performing in front of a crowd.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Washington, DC, 1994.
Important factors to consider when diagnosing an anxiety disorder:
- Determine whether there is a medical cause for the anxiety symptoms. Sometimes an older adult really is having a heart attack––not a panic attack!
- The symptoms, frequency, and intensity of anxiety and the behaviors that result from an anxiety disorder vary among individuals.
More specialized assessments
Some patients, especially those who have a combination of panic disorder and depression, may also require evaluation for:
- Medical problems. This evaluation can include laboratory and other examinations such as thyroid function tests, serum glucose, and ECG.
- Psychological issues.
- Substance abuse.
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Management
Management of anxiety disorders may include medication therapy, psychotherapy, or both.
Medication
Several types of medications are effective in managing anxiety. Factors that are considered in choosing a medication include the patient s age, coexisting medical and psychiatric illnesses, prior response to medications, and possible drug-drug interactions.
Anti-depressants. Several antidepressants are now approved by the FDA to treat anxiety disorders. Fluoxetine and flovoxamine are approved to treat OCD. Sertraline and paroxetine are approved to treat PTSD. Paroxetine is indicated in the treatment of social phobia. These medications can help to ease both anxiety and related depression. They can also reduce the strength and number of a patient s panic attacks and avoidance behaviors.
These medicines are associated with side effects such as headaches, GI upset, diarrhea, insomnia, and sexual side effects. Sometimes they are associated with restlessness or agitation and the onset of suicidal thoughts. These side effects should be reported immediately to the doctor who prescribed the medication
Tricyclic anti-depressants (TCAs) such as imipramine are generally as effective as SSRIs in reducing anxiety, although these drugs are not always as well tolerated as SSRIs. The side effects of TCA therapy can include cardiovascular and anticholinergic problems.
Other antidepressants that may be used to treat anxiety disorders are: venlafaxine and trazodone (for panic disorder); and bupropion (primarily for depression and as an adjunctive treatment for patients with panic disorder who experience sexual dysfunction after taking other antidepressant drugs).
Anti-anxiety medications such as benzodiazepines (e.g., alprazolam) are sometimes prescribed for fast control of anxiety symptoms when the patient is in a crisis situation. However, benzodiazepines can be addictive and are generally not prescribed for long-term use. They also should not be used by individuals who have a history of substance abuse.
Monoamine oxidase inhibitors (MAOIs), like some anti-depressant and anti-anxiety drugs, can effectively reduce anxiety, the number of panic attacks and avoidance behaviors, and related depression. When taking an MAOI, a patient must be careful about his diet and other medicines he is taking. Certain foods and medicines, when combined with an MAOI, can produce very high blood pressure that has been associated with heart attacks, strokes, and other complications. Thus, MAOIs are usually prescribed for patients who do not respond to other medications; they are mainly prescribed by psychiatrists.
Beta blockers such as propranolol are sometimes prescribed in combination with benzodiazepines such as alprazolam.
Psychotherapy
Psychosocial interventions for anxiety disorders include cognitive behavioral therapy (CBT), group therapy (such as marital and family therapy), and psychodynamic psychotherapy to address coexisting disorders or stressors. Support, reassurance, and education are important elements of each of these interventions.
Cognitive behavioral therapy (CBT) is the most common form of psychotherapy to reduce anxiety in older adults. This type of therapy can last up to several months. CBT treatments may include:
- Relaxation therapy such as breathing retraining and mindfulness meditation; this type of therapy may be conducted in a group setting.
- Cognitive restructuring (replacing worries with more realistic, less catastrophic thoughts)
- Continuous panic monitoring (patients keep track of their panic attacks using a diary; this information can be used to establish a pattern between the individual s symptoms of anxiety and environmental and situational triggers), and
- Regular exposure to feared objects or situations.
Group therapy may include marital and family therapy as well as medication support groups and consumer-run self-help groups. Group therapy can be particularly effective for individuals with agoraphobia and panic disorders.
Psychodynamic psychotherapy to address coexisting disorders or stressors is often used in addition to CBT and/or medications.
Combined pharmacotherapy and psychotherapy
Because of the broad range of symptoms among older adults who experience anxiety disorders, it is not possible to make a general recommendation regarding the efficacy of medication, psychotherapy, or a combination of the two types of therapy. However, combination therapy (e.g., medication and CBT) may be especially helpful for individuals who have panic disorders such as severe agoraphobia.
Suggested Guidelines for Treatment
Treatment of an anxiety disorder usually begins by reassuring the individual and his or her family that panic attacks, although frightening, are not life threatening. Without treatment, however, these attacks can become debilitating.
The clinician should be aware of the wide variety of other medical and psychiatric conditions that mimic anxiety disorders.
In addition to these considerations, the decision to use one treatment method over another may depend in part on:
- The patient’s other medical or psychiatric illnesses
- His or her history of substance use
Care for suicidal patients
Refer patients who present safety risks to themselves or others to a hospital emergency department.
Acute treatment
The acute phase of treatment for anxiety with either pharmacotherapy or psychotherapy lasts approximately 12 weeks. For the patient who is undergoing CBT, many clinicians then reduce the frequency of therapeutic sessions and gradually end treatment when the patient is stable.
The patient may not notice the effects of either pharmacotherapy or psychotherapy for several weeks after treatment begins. Patients who suffer from severe panic attacks may benefit from short-term use of benzodiazepines.
Regardless of whether the patient is undergoing pharmacotherapy or psychotherapy, if his or her anxiety is not reduced within 6 – 8 weeks of treatment, the mental health professional should reevaluate the patient s diagnosis and treatment plan. He or she may require a different treatment or a combined therapeutic approach.
- Lack of a response to anti-anxiety medication or repeated relapses may be due to:
- Non-compliance
- Inadequate dosing
- Inadequate duration of therapy
- The need for psychotherapy as well
- Look for improvement in the patient s:
- Thoughts about suicide
- Signs and symptoms of anxiety
- Sleep patterns
- Relationships
Continuation treatment
If the individual is taking medication for anxiety, he or she may continue to take the drug for 12 – 18 months before it is discontinued. If the patient experiences a relapse after discontinuing the medication, pharmacotherapy may continue and he or she may be offered CBT as well.
A patient’s fear that panic attacks may recur often continues even after the attacks have ended. His or her presenting symptoms should be monitored regularly. The clinician should also be watchful for signs of depression, which can develop even during successful treatment of an anxiety disorder.
Discontinuing active treatment
Anxiety disorders sometimes recur after treatment has been discontinued. If this happens, the patient should be instructed to contact his or her mental health professional right away. Beginning therapy again usually leads to improvement.
Adapted from:
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