Evidence-Based Reviews

How anxiety presents differently in older adults

Current Psychiatry. 2011 March;10(3):65-72

Age-related changes, medical comorbidities alter presentation and treatment

References

1. Fuentes K, Cox BJ. Prevalence of anxiety disorders in elderly adults: a critical analysis. J Behav Ther Exp Psychiatry. 1997;28:269-279.

2. Préville M, Hérbert R, Bravo G, et al. Predisposing and facilitating factors of severe psychological distress among frail elderly. Can J Aging. 2002;21:195-204.

3. Le Roux H, Gatz M, Wetherell JL. Age at onset of generalized anxiety disorder in older adults. Am J Geriatr Psychiatry. 2005;13:23-30.

4. Beekman AT, Bremmer MA, Deeg DJ, et al. Anxiety disorders in later life: a report from the Longitudinal Aging Study Amsterdam. Int J Geriatr Psychiatry. 1998;13:717-726.

5. Regier DA, Rae DS, Narrow WE, et al. Prevalence of anxiety disorders and their comorbidity with mood and addictive disorders. Br J Psychiatry Suppl. 1998;34:24-28.

6. Gum AM, King-Kallimanis B, Kohn R. Prevalence of mood anxiety, and substance-abuse disorders for older Americans in the national comorbidity survey-replication. Am J Geriatr Psychiatry. 2009;17(9):769-781.

7. Sareen J, Jacobi F, Cox BJ, et al. Disability and poor quality of life associated with comorbid anxiety disorders and physical conditions. Arch Intern Med. 2006;166:2109-2116.

8. Porensky EK, Dew MA, Karp JF, et al. The burden of late-life generalized anxiety disorder: effects on disability, health-related quality of life, and healthcare utilization. Am J Geriatr Psychiatry. 2009;17(6):473-482.

9. Tinetti ME, Inouye SK, Gill TM, et al. Shared risk-factors for falls, incontinence, and functional dependence: unifying the approach to geriatric syndromes. JAMA. 1995;273:1348-1353.

10. Lenze EJ, Karp JF, Mulsant BH, et al. Somatic symptoms in late-life anxiety: treatment issues. J Geriatr Psychiatry Neurol. 2005;18:89-96.

11. Gibbons LE, Teri L, Logsdon R, et al. Anxiety symptoms as predictors of nursing home placement in patients with Alzheimer’s disease. Journal of Clinical Geropsychology. 2002;4:335-342.

12. de Beurs E, Beekman AT, van Balkom AJ, et al. Consequences of anxiety in older persons: its effect on disability, well-being and use of health services. Psychol Med. 1999;29(3):583-593.

13. Schoevers RA, Beekman AT, Deeg DJ, et al. Comorbidity and risk-patterns of depression, generalised anxiety disorder and mixed anxiety-depression in later life: results from the AMSTEL study. Int J Geriatr Psychiatry. 2003;18:944-1001.

14. Wilk J, West J, Narrow W, et al. Are anxiety disorders underdiagnosed and undertreated in routine psychiatric practice? Poster presented at: AcademyHealth Annual Meeting; June 8, 2004; San Diego, CA.

15. Chou KL. Age at onset of generalized anxiety disorder in older adults. Am J Geriatr Psychiatry. 2009;17(6):455-464.

16. Howland J, Peterson EW, Levin WC, et al. Fear of falling among the community-dwelling elderly. J Aging Health. 1993;5(2):229-243.

17. Kohn R, Westlake RJ, Rasmussen SA, et al. Clinical features of obsessive-compulsive disorder in elderly patients. Am J Geriatr Psychiatry. 1997;5(3):211-215.

18. Flint AJ. Epidemiology and comorbidity of anxiety disorders in the elderly. Am J Psychiatry. 1994;151:640-649.

19. Skoog G, Skoog I. A 40-year follow-up of patients with obsessive-compulsive disorder. Arch Gen Psychiatry. 1999;56(2):121-127.

20. Nestadt G, Bienvenu OJ, Cai G, et al. Incidence of obsessive-compulsive disorder in adults. J Nerv Ment Dis. 1998;186:401-406.

21. Chacko RC, Corbin MA, Harper RG. Acquired obsessive-compulsive disorder associated with basal ganglia lesions. J Neuropsychiatry Clin Neurosci. 2000;12:269-272.

22. Mittal D, Torres R, Abashidze A, et al. Worsening of post-traumatic stress disorder symptoms with cognitive decline: case series. J Geriatr Psychiatry Neurol. 2001;14(1):17-20.

23. Tedstone JE, Tarrier N. Posttraumatic stress disorder following medical illness and treatment. Clin Psychol Rev. 2003;23(3):409-448.

24. Creamer M, Parslow R. Trauma exposure and posttraumatic stress disorder in the elderly: a community prevalence study. Am J Ger Psychiatry. 2008;16:853-856.

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26. Boyd R, Stevens JA. Falls and fear of falling: burden beliefs and behaviours. Age Ageing. 2009;38(4):423-428.

27. Cairney J, McCabe L, Veldhuizen S, et al. Epidemiology of social phobia in later life. Am J Geriatr Psychiatry. 2007;15(3):224-233.

28. Pontillo DC, Lang AJ, Stein MB. Management and treatment of anxiety disorders in the older patient. Clinical Geriatrics. 2002;10(10):38-49.

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Discuss this article at http://currentpsychiatry.blogspot.com/2011/03/how-anxiety-presents-differently-in.html#comments

Although anxiety disorders are common at all ages, there is a misconception that their prevalence drastically declines with age. For this reason anxiety disorders often are underdiagnosed and undertreated in geriatric patients, especially when the clinical presentation of these disorders in older patients differs from that seen in younger adults.

In older persons, anxiety symptoms often overlap with medical conditions such as hyperthyroidism and geriatric patients tend to express anxiety symptoms as medical or somatic problems such as pain rather than as psychological distress.¹ As a result, older adults often seek treatment for depressive or anxiety symptoms from their primary care physician instead of a psychiatrist. Unfortunately, primary care physicians often miss psychiatric illness, including anxiety disorders, in geriatric patients.

Anxiety may be a symptom of an underlying psychiatric disturbance, secondary to a general medical condition, or induced by dietary substances, substances of abuse, or medications. Late-life anxiety often is comorbid with major depressive disorder (MDD) ( Box ) and other psychological stressors as older adults recognize declining cognitive and physical functioning.² Anxiety disorders commonly begin in early adulthood, tend to be chronic and interspersed with remissions and relapses, and usually continue into old age.³ In generalized anxiety disorder (GAD), there is a bimodal distribution of onset; approximately two-thirds of patients experience onset between the late teens and late 20s and one-third develop the disorder for the first time after age 50.³

Prevalence rates for anxiety disorders among older adults (age ≥55) range from 3. 5% to 10. 2%.⁴ These rates are slightly lower than those for younger adults.⁵ Among older adults, presence of a 12-month anxiety disorder was associated with female sex, lower education, being unmarried, and having ≥3 or more chronic conditions.⁶

Box

Comorbid anxiety and depression: Highly prevalent, poorer outcomes

The Longitudinal Aging Study Amsterdam study—one of the largest epidemiologic studies to examine comorbidity of anxiety disorders and depression in patients age 55 to 85—found that 48% of older persons with primary major depressive disorder (MDD) also had a comorbid anxiety disorder, whereas approximately one-fourth of those with anxiety disorders also had MDD.^a Pre-existing anxiety disorders, such as social phobia, obsessive-compulsive disorder, specific phobia, agoraphobia, and panic disorder, increase the risk of developing depression.^b Rates of comorbid anxiety and depression increase with age.^c

Late-life MDD comorbid with generalized anxiety disorder or panic disorder is associated with greater memory decline than MDD alone.^d In addition, comorbid anxiety and depression is associated with greater symptom severity and persistence, greater functional impairment, substance dependence, poorer compliance and response to treatment, worse overall prognosis and outcome than patients with either disorder alone,^e and greater likelihood of suicidal ideation in older men.^f

References

a. Beekman AT, de Beurs E, van Balkom AJ, et al. Anxiety and depression in later life: co-occurrence and communality of risk factors. Am J Psychiatry. 2000; 157(1): 89-95.

b. Goodwin RD. Anxiety disorders and the onset of depression among adults in the community. Psychol Med. 2002; 32: 1121-1124.

c. Merikangas KR, Zhang H, Avenevoli S, et al. Longitudinal trajectories of depression and anxiety in a prospective community study: the Zurich Cohort Study. Arch Gen Psychiatry. 2003; 60: 993-1000.

d. DeLuca AK, Lenze EJ, Mulsant BH, et al. Comorbid anxiety disorder in late life depression: association with memory decline over four years. Int J Geriatr Psychiatry. 2005; 20(9): 848-854.

e. Merikangas KR, Kalaydjian A. Magnitude and impact of comorbidity of mental disorders from epidemiologic surveys. Curr Opin Psychiatry. 2007; 20: 353-358.

f. Lenze E, Mulsant BH, Shear MK, et al. Comorbid anxiety disorders in depressed elderly patients. Am J Psychiatry. 2000; 157: 722-728.

Anxiety and disability risk

Clinical Point

Handwashing and fear of having sinned are more common in older OCD patients than in younger ones

Anxiety disorders affect geriatric patients more profoundly than their younger counterparts. Persons age ≥65 who have an anxiety disorder are 3 to 10 times more likely to be hospitalized than younger individuals.¹ Anxiety is associated with high rates of medically unexplained symptoms, increased use of health care resources, chronic medical illness, low levels of physical health-related quality of life, and physical disability.^7,8

Anxiety symptoms may predict progressing physical disability among older women and reduced ability to perform activities of daily living over 1 year.⁹ Anxious geriatric patients are less independent and increase the burden on family and caregivers.¹⁰ Anxiety disorders are associated with lower compliance with medical treatment, which could worsen chronic medical conditions and increase the risk for nursing home admission.¹¹ Anxious older adults report decreased life satisfaction, memory impairment, poorer self perception of health, and increased loneliness.¹²