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Anxiety disorders in older people 

Anxiety disorders in older people
Chapter:
Anxiety disorders in older people
Author(s):

Gerard Byrne

DOI:
10.1093/med/9780199644957.003.0045
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Fear and anxiety are phylogenetically ancient emotions that confer survival advantage across species (Darwin, 1872). They facilitate escape from present danger and prepare the individual to deal rapidly with future threats. In contemporary life, a moderate increase in anxiety is commonly associated with increased performance (Yerkes and Dodson, 1908). However, anxiety that is excessive or prolonged is maladaptive and may represent a mental disorder. Individual differences and contextual factors influence the final form that an anxiety disorder takes. Like many complex behaviours, anxiety disorders result from interactions between genetic and environmental factors. In older people, anxiety often complicates physical frailty and cognitive decline. From a nosological perspective, anxiety can be conceptualized as both dimensional and categorical. Both psychological and pharmacological treatments are commonly applied to anxiety disorders in older people, with moderate efficacy. This chapter deals with classification, epidemiology, scientific underpinnings, phenomenology, and modern treatment approaches to anxiety disorders in later life.

Classification

The tenth edition of the International Classification of Diseases (ICD-10) includes anxiety disorders within a broader category of neurotic, stress-related, and somatoform disorders (World Health Organization, 2010). In contrast, DSM-IV has a separate section for anxiety disorders (American Psychiatric Association, 2000). Both systems include obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) under these rubrics. Table 45.1 shows the classification of anxiety disorders under ICD-10 and DSM-IV. There is substantial commonality between the lists of anxiety disorders under the two dominant nosologies, reflecting convergence over time. Both of these classification systems are currently under revision, with ICD-11 due in 2015 and DSM-5 due in April 2013. Several changes have been proposed to the diagnostic criteria for anxiety disorders in DSM-5. Most significantly, it has been proposed to reduce the minimum duration of symptoms in generalized anxiety disorder (GAD) from 6 months to 3 months (Andrews et al., 2010). This is likely to have the effect of increasing the overall prevalence of GAD in adults but not altering its severity (Andrews and Hobbs, 2010). However, it is likely to have less impact on the measured prevalence of GAD in older people, as most GAD has its onset earlier in life. Another significant change is mooted for criterion A of PTSD. It has been proposed to tighten up PTSD criterion A1, which describes the nature of the traumatic exposure, and to delete criterion A2, which requires the person to have experienced ‘intense fear, helplessness or horror’ at the time of the traumatic exposure (Friedman et al., 2011).

Table 45.1 Anxiety disorder classification in ICD-10 and DSM-IV

ICD-10

DSM-IV

F40.0 Agoraphobia, unspecified

300.22 Agoraphobia without history of panic disorder

F40.02 Agoraphobia without panic disorder

F40.1 Social phobia

300.23 Social phobia

F40.2 Specific phobia

300.29 Specific phobia

F41.0 Panic disorder

300.01 Panic disorder without agoraphobia

F40.01 Agoraphobia with panic disorder

300.21 Panic disorder with agoraphobia

F41.1 Generalized anxiety disorder

300.02 Generalized anxiety disorder

F41.2 Mixed anxiety and depressive disorder

F41.3 Other mixed anxiety disorders

Proposed for DSM-5

F42 Obsessive compulsive disorder

300.3 Obsessive-compulsive disorder

F43.0 Acute stress disorder

308.3 Acute stress disorder

F43.1 Post-traumatic stress disorder

309.81 Post-traumatic stress disorder

F43.22 Adjustment disorder with anxiety

309.24 Adjustment disorder with anxiety

F43.23 Adjustment disorder with mixed anxiety and depressed mood

309.28 Adjustment disorder with mixed anxiety and depressed mood

F06.4 Anxiety disorder due to a known physiological condition

293.84 Anxiety disorder due to a general medical condition

Various disorders listed under F10–F19

292.89 Substance-induced anxiety disorder

F41.0 Anxiety disorder, unspecified

300.00 Anxiety disorder not otherwise specified

Epidemiology

There is now a substantial literature on the prevalence of anxiety disorders in older people, although a firm consensus is yet to emerge due to unresolved substantive and methodological issues. (Bryant et al. 2008) have reviewed anxiety disorder prevalence estimates and associated methodological issues. Most population-based surveys find that the prevalence rates for anxiety disorders fall significantly after the age of about 50 years. The reasons for this oft-repeated observation are unclear. The observation that this effect begins in middle age makes it particularly challenging to explain using conventional age-related arguments. It has been suggested that the diagnostic interviews used to detect anxiety disorders are not appropriate for use in older people (O’Connor, 2006; O’Connor and Parslow, 2010), or that the diagnostic criteria themselves have intrinsic age biases. Anxiety disorder prevalence rates are higher in women than men at all ages, including later life. This is reflected in the age by sex distribution of anxiety disorder prevalence in national population-based surveys (see Fig. 45.1). However, there is some evidence that the sex difference in anxiety prevalence might decline in advanced old age (Pachana et al., 2012).

Fig. 45.1 Twelve-month prevalence of anxiety disorders by age and sex. (Australian Bureau of Statistics (2007). National Survey of Mental Health and Wellbeing; ABS Cat. No. 4326.0.)

Fig. 45.1
Twelve-month prevalence of anxiety disorders by age and sex. (Australian Bureau of Statistics (2007). National Survey of Mental Health and Wellbeing; ABS Cat. No. 4326.0.)

Table 45.2 provides a summary of nonhierarchical 12-month population prevalence estimates for anxiety disorders according to DSM-IV and ICD-10 criteria in persons aged 65–85 years and in persons aged 16–64 years, based on the 2007 Australian National Survey of Mental Health and Wellbeing (NSMHWB) (Australian Bureau of Statistics, 2007). This population survey employed trained lay interviewers, who used the Composite International Diagnostic Interview (CIDI). The survey included 1905 community-residing persons aged 65 years and over, but it did not sample persons residing in hospitals, nursing homes, or caravan parks. The two diagnostic systems generated somewhat different prevalence estimates for panic disorder, agoraphobia, and PTSD, with ICD-10 providing higher estimates in each case. The survey did not measure the prevalence of simple phobia. The population prevalence estimates in Table 45.2 are associated with relatively wide confidence intervals (CI), indicating the level of imprecision with which the estimates were made. The variations in prevalence estimates between the DSM-IV and ICD-10 nosological systems can be explained by differences in their diagnostic criteria. To illustrate this, let us take panic disorder as an example. Both DSM-IV and ICD-10 require a person with panic disorder to experience multiple, unexpected panic attacks, and the definitions of a panic attack are similar under each system. The main difference is that ICD-10 requires the person simply to experience recurrent panic attacks (World Health Organization, 2010), whereas DSM-IV requires the person to experience recurrent panic attacks and one or more sequelae, including a persistent concern about having another attack, worry about the implications or consequences of the attack, or a significant change in behaviour following the attack (American Psychiatric Association, 2000). Thus, in NSMHWB, similar proportions of older people reported having experienced panic attacks in the past 12 months under the DSM-IV and ICD-10 criteria, but the absence in ICD-10 of the requirement for one or more panic attack sequelae meant that the prevalence of panic disorder was much higher under this system than when the DSM-IV criteria were applied (see Table 45.2). So these different prevalence estimates do not reflect minor methodological issues, but major differences in the way disorders are conceptualized or formalized. These differences might need to be taken into consideration when basing service development or funding decisions on epidemiological data.

Table 45.2 Twelve-month prevalence rates (%) for DSM-IV and ICD-10 anxiety disorders

DSM-IV 12-month prevalence (95% CI)

ICD-10 12-month prevalence (95% CI)

65–85 years

16–64 years

65–85 years

16–64 years

Generalized anxiety disorder

1.4 (0.8–1.9)

4.3 (3.8–4.7)

1.5 (1.0–2.1)

3.7 (3.3–4.1)

Panic disorder

0.5 (0.2–0.9)

2.2 (1.9–2.6)

0.9 (0.5–1.4)

3.1 (2.7–3.5)

Agoraphobia (+/− panic disorder)

0.3 (0.1–0.6)

1.6 (1.3–1.9)

1.0 (0.6–1.5)

3.4 (3.0–3.9)

Social phobia

1.2 (0.7–1.7)

5.4 (4.8–5.9)

1.3 (0.8–1.8)

5.8 (5.3–6.4)

Post-traumatic stress disorder

1.6 (1.1–2.2)

5.3 (4.8–5.8)

2.5 (1.8–3.2)

7.9 (7.3–8.6)

Obsessive-compulsive disorder

0.7 (0.4–1.1)

3.1 (2.7–3.5)

0.7 (0.4–1.1)

2.4 (2.0–2.7)

Any anxiety disorder

4.3 (3.3–5.2)

14.2 (13.4–15.0)

6.0 (4.9–7.1)

17.1 (16.1–17.9)

These population-weighted estimates were calculated from the confidentialized unit record file of the National Survey of Mental Health and Wellbeing, Australian Bureau of Statistics (2007). All diagnoses are nonhierarchical.

One method of attempting to sort out the validity of competing diagnostic approaches in a clinically meaningful way is to measure the degree of distress and disability associated with a diagnosis. Using the 12-item Short Form Health Survey (SF-12) to gauge disability, Slade and Andrews (2001) have shown in adults 18 years and over that DSM-IV GAD is associated with greater disability than ICD-10 GAD.

The Longitudinal Ageing Study Amsterdam (LASA) used a two-stage design to investigate the consequences of anxiety disorder and anxiety symptoms in people aged 55–85 years (de Beurs et al., 1999). The anxiety disorders studied were panic disorder, GAD, OCD, and phobic disorders. Older people with an anxiety disorder, or with anxiety symptoms, reported worse perceived health, greater loneliness, worse life satisfaction, and greater health services utilization than age-matched controls (de Beurs et al., 1999). In a US study of people aged 60–80 years who were seeking treatment for GAD and a matched control group, (Wetherell et al. 2004) analysed quality of life using the 36-item Short Form Health Survey (SF-36). In this study, GAD was associated with worse health-related quality of life across almost all SF-36 domains and these associations were present regardless of whether GAD was complicated by comorbid psychiatric disorder. In addition, (Porensky et al. 2009) have demonstrated that older people with DSM-IV GAD have higher disability, worse health-related quality of life, and greater healthcare utilization than matched comparison participants without GAD.

The incidence of anxiety disorders in older people has been less well studied. However, using data from Wave 2 of the US National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV), (Chou et al. 2011) estimated the weighted 3-year incidence of nonhierarchical DSM-IV anxiety disorders in 8012 persons aged 60 years and over as follows: GAD 1.63%; specific phobia 1.35%; panic disorder 0.76%; and social phobia 0.58%. Incidence estimates for other anxiety disorders were not reported. Participants aged 80 years and over were at greater risk of incident panic disorder than participants aged 60–79 years. PTSD at baseline predicted incident GAD, panic disorder, and specific phobia, whereas panic disorder at baseline predicted incident social phobia. In addition, personality disorder at baseline predicted incident GAD, panic disorder, and social phobia, but not specific phobia. Interestingly, after adjustment for other psychiatric disorders and sociodemographic factors, neither adverse life events nor measures of general health were related to incident anxiety disorder in this particular cohort (Chou et al., 2011; Mackenzie et al., 2011). It is not appropriate to compare the incidence rates from NESARC with the prevalence rates from NSMHWB as the age ranges, cohort characteristics, and diagnostic instruments all differed.

A significant minority of older people with an anxiety disorder also meets diagnostic criteria for a comorbid psychiatric disorder. For example, of older people with a DSM-IV 12-month anxiety disorder in the NSMHWB study, 60% met diagnostic criteria for a single anxiety disorder, 14% met criteria for at least one additional anxiety disorder, and 26% met criteria for at least one additional mood or substance use disorder. Similarly, of older people with a DSM-IV 12-month anxiety disorder, 78% had a comorbid physical disorder (Australian Bureau of Statistics,, 2007). In contrast, of older NSMHWB participants with a 12-month history of affective disorder, 45.5% also had a 12-month history of anxiety disorder. These observations are important because there is a long-standing myth that anxiety in pure culture is uncommon in older people. Bereavement reactions are also commonly complicated by anxiety disorders, particularly GAD and PTSD (Zisook et al., 1990).

Although the prevalence of anxiety disorders in community-residing older people is lower than in young or middle-aged persons, older people with other health problems have been shown to experience a high prevalence of anxiety disorder. (Smalbrugge et al. 2005) found that 29.7% of 333 Dutch nursing home residents had anxiety symptoms, 4.2% had subthreshold anxiety disorders, and 5.7% had an anxiety disorder. Residents with stroke or depression were at greater risk of an anxiety disorder. (Chemerinski et al. 1998) assessed 398 patients with Alzheimer’s disease and found that 5% met diagnostic criteria for GAD over the previous 4 weeks. In the Cache County study, (Lyketsos et al. 2001) found that anxiety symptoms were present in 10–12% of patients with Alzheimer’s disease of varying severities. Anxiety also occurs commonly in the context of mild cognitive impairment (MCI) (Monastero et al. 2009) and its presence in MCI appears to be part of the prodrome of Alzheimer’s disease (Gallagher et al., 2011). Moreover, it seems that individuals with normal cognition, but who are at increased risk of developing the clinical manifestations of Alzheimer’s disease in the future, also have increased anxiety. (Lavretsky et al. 2009) found that anxiety symptoms in middle-aged and older adults without dementia were associated with cerebral amyloid load, as demonstrated by FDDNP-PET (positron emission tomography) binding.

Biological Factors

Although the prefrontal cortex is involved in social cognition, it is the more phylogenetically ancient limbic system that is most involved in fear and anxiety responses. The limbic system includes the insular cortex, the cingulate gyrus, the hippocampus, and the amygdala. The amygdala is particularly important for the generation of panic (Davis, 1992) and there is evidence that fear responses in the amygdala are ‘hard-wired’ and difficult to extinguish (Sah and Westbrook, 2008). The presence of fear-related circuits involving the amygdala, insula, and anterior cingulate has been demonstrated in humans on neuroimaging studies with both functional magnetic resonance imaging (fMRI) and PET (Sehlmeyer et al., 2009).

The hippocampus modulates the activity of the hypothalamic–pituitary–adrenal axis, dampening down stress responses (Davis, 1992). There is evidence that both hippocampal volume and neurogenesis are implicated in the response to stress. Although more research in humans is needed, individuals with greater hippocampal volume and intact hippocampal neurogenesis appear to have greater resilience (Martin et al., 2009). In research on twins discordant for combat exposure in Vietnam, those with smaller hippocampi were vulnerable to PTSD following combat exposure, whereas twins with normal hippocampi or without combat exposure did not have an elevated rate of PTSD (Gilbertson et al., 2002). Thus, both the biological vulnerability demonstrated by small hippocampi and the environmental stimulus of combat exposure were necessary before PTSD developed.

Studies in monozygotic and dizygotic twins indicate that about 30–40% of the variation in the risk of anxiety disorder is of genetic origin (Norrholm and Ressler, 2009). No genes of large effect have yet been identified (Schumacher et al., 2011), so polygenic influences are likely. There is some evidence that genetic factors might play a greater part in the aetiology of panic disorder than of GAD. Polymorphisms in the promoter region of the 5-HT transporter gene have been linked to risk of anxiety disorder (Xie et al., 2009). Individuals who are homozygous for the s allele of this promoter exhibit greater fMRI responses in the amygdala to fearful stimuli and report higher levels of neuroticism (Davis, 1992). In a study of survivors of the Rwandan genocide, (Kolassa et al. 2010) found that the risk of PTSD depended upon both the traumatic load and the catechol-o-methyltransferase Val(158)Met polymorphism. Individuals with Val polymorphisms developed PTSD following trauma in a dose-response manner, whereas trauma-exposed individuals homozygous for the Met/Met polymorphism were at high risk of PTSD regardless of the level of their traumatic exposure. This same genetic polymorphism might also predict response to treatment (Lonsdorf et al., 2010), although more work is needed before these findings are translated into clinical practice.

Experiments in laboratory animals demonstrate the importance of the early environment in the development of anxiety. Rats separated from their mothers for several hours a day in the early postnatal period demonstrate increased hormonal reactivity to stress and increased anxiety-related behaviours (Kalinichev et al., 2002). In addition, rats raised by mothers with impaired licking and grooming behaviour are at increased risk of developing anxiety, with cross-fostering experiments indicating that this effect is mainly of environmental origin (Liu et al., 2000). Although it is clear that anxiety symptoms and anxiety disorders are due to a combination of genetic and environmental factors, a question that arises is whether genetic influences are less important in later life. (Gillespie et al. 2004) found that this was not the case for late-life anxiety and depression, although there were differences between genetic influences in men and women. More specifically, there were additional midlife and late-life genetic influences in women. Thus, it seems that genetic effects are still operating strongly in later life.

Psychological Factors

Normal anxiety is conventionally divided into trait anxiety and state anxiety. Both are dimensional rather than categorical constructs. Levels of trait anxiety are relatively stable over the lifespan, indicating the influence of genetic and early environmental influences. In contrast, levels of state anxiety fluctuate over time, reflecting responses to aversive stimuli throughout life. However, state anxiety is also influenced by genetic factors. In the dimensional ‘five-factor’ model of normal personality, high neuroticism is associated with anxiety symptoms and all anxiety disorders. In addition, high conscientiousness is associated with GAD and OCD, whereas low extraversion is associated with social phobia (Rosellini and Brown, 2011). In older adults, neuroticism and GAD are both moderately heritable (0.47 and 0.27, respectively), and approximately one-third of the genetic influence on GAD is shared with trait neuroticism (Mackintosh et al., 2006). Even in people with Alzheimer’s disease, informant-rated premorbid neuroticism has been found to be associated with current anxiety on the Neuropsychiatric Inventory (Archer et al., 2007).

In both laboratory animals and humans, a new fear response develops when a harmless context or cue (conditioned stimulus (CS)) is paired with an aversive event (unconditioned stimulus (US)). Although the fear response to the CS can be extinguished by habituation—repeated exposure to the CS in the absence of the US—it is rapidly reinstated by either simultaneous re-exposure to the CS and US or sequential re-exposure to the US followed shortly by the CS, indicating that learnt fear is strongly retained (Sah and Westbrook, 2008). This observation is likely to at least partially explain the chronicity of many anxiety disorders and why the response to short-term treatment is often poorly sustained. Avoidance behaviour leads to a temporary reduction in anxiety, which negatively reinforces (increases) avoidance behaviour. However, avoidance is not a successful long-term strategy as it makes anxiety worse by preventing habituation to the feared stimulus. Avoidance is thus key to maintenance of the fear response, and dealing with avoidance is critical to successful treatment of most anxiety disorders. Exposure and behavioural activation paradigms that reduce avoidance behaviours have been used as the basis for interventions for anxiety disorders (Cherbuin et al., 2008).

Hyperventilation is a common symptom of panic attacks, and for many years it was also considered to be a cause of panic (Griez and Schruers, 1998). However, inhaled carbon dioxide precipitates panic so it appears that it is hypercapnia not hypocapnia that leads to panic. This makes physiological sense, and has been referred to as the suffocation false alarm theory (Klein, 1993; Maddock, 2001). The relationships between panic, acid-base metabolism, and hyperventilation are complex and poorly understood, although it has been argued that chronic hyperventilation is a response to metabolic acidosis (Sikter et al., 2007).

There is evidence that anxiety disorders in later life are associated with childhood abuse or neglect. Analysis of data from the US National Comorbidity Study Replication (NCS-R) showed that childhood sexual abuse was associated with social phobia, panic disorder, GAD, and PTSD, whereas childhood physical abuse was associated with specific phobia and PTSD (Cougle et al., 2010). There is evidence also that childhood physical abuse is associated with an earlier age of onset of GAD (Gonçalves and Byrne, 2012a).

From a psychodynamic perspective, anxiety can be understood as arising out of uncontrolled fear and guilt that has its origins in earlier developmental periods. Emotions related to aggression and sexuality can be experienced as dangerous and be repressed, resulting in anxiety symptoms.

Anxiety Symptoms

Anxiety symptoms are diverse but are conventionally clustered under the three headings of physical, mental, and emotional. Physical symptoms are multifarious and can be experienced in any bodily system. They include palpitations, dyspnoea, chest tightness, dizziness, sweating, itch, blushing, nausea, teeth grinding, choking, butterflies in the stomach, diarrhoea, frequent urination, fatigue, weakness, muscle tension, tremor, and insomnia. Mental symptoms include worry, rumination, depersonalization, derealization, poor concentration, and memory impairment. Worry can be about many different topics. Emotional symptoms include fear, dread, anger, depression, emotional numbness, irritability, and tearfulness. Fear can be directed towards many objects or situations. Anxiety is also associated with a variety of behaviours, including avoidance of feared objects or situations, and repetitive checking or washing.

Panic

Panic attacks are conventionally defined as rapidly escalating anxiety episodes in which fear and apprehension rise to a crescendo within 10 min and then subside over several hours. Panic attacks are associated with a wide variety of physical symptoms, including shortness of breath, tachycardia, palpitations, a choking sensation, chest tightness, sweating, tremor, paraesthesiae, nausea, and hot or cold flushes. People experiencing a panic attack commonly catastrophize about their symptoms and fear collapse, stroke, or death. Sometimes they think they will ‘go crazy’ or embarrass themselves in front of others. People having a panic attack often make frantic attempts to escape from the situation in which the panic attack occurred. They often go on to develop anticipatory anxiety about having further panic attacks.

Worry

Worry is a core manifestation of generalized anxiety and can be conceptualized as an attempt to solve feared events with uncertain outcomes (Borkovec et al., 1983). Overall, older people report fewer worries than young or middle-aged people (Lindesay et al., 2006; Coelho et al., 2010). Worry in later life is often directed towards different content areas than in younger adults. While older people are more likely than younger adults to worry about the health and welfare of loved ones, they are less likely to worry about work, health, and interpersonal relationships (Gonçalves and Byrne, 2013). Thus, there appear to be developmental aspects to worry content. At first glance, it might seem counterintuitive that older people should report fewer worries than younger people, given the common challenges of ageing and likely reduced opportunities for older people to habituate through exposure. The consistently verified reduction in worry frequency with age has been attributed to several complementary factors, including increased emotional regulation, changes in daily demands, the influence of cognitive habituation mechanisms, and cohort effects (Gonçalves and Byrne, 2013). Other factors, including data censoring due to premature death or institutionalization of worriers, and the use of assessment measures that are inappropriate for older people, might also explain some of the measured differences in worry prevalence (Gonçalves and Byrne, 2013).

Fear of crime among older people, especially older women, is a particular category of worry that is commonly promoted by mass media (Reiner, 2007). In most countries, it is associated with the paradox that older people are the least likely group to be either victims or perpetrators of crime. Of course, older people have lived longer than younger people and have thus had the opportunity to observe both more actual crime and more reports of crime. In a small US study, predictors of fear of crime among older people were found to be female gender, non-Caucasian ethnicity, depressive symptoms, and social isolation (Acierno et al., 2004). Housebound older women might experience greater levels of fear of violence than other groups (Barnett et al., 2007). In a UK study based on the Whitehall II cohort (middle-aged adults), fear of crime was associated with poorer physical and mental health and lower quality of life (Stafford et al., 2007). The specific association of fear of crime with anxiety disorders in later life needs further study.

Avoidance

Avoidance behaviour in older people can take many different forms and clinicians sometimes underestimate its severity and extent. Older people might avoid participating in everyday social activities by referring to commonplace physical complaints. They might give up driving a motor vehicle prematurely or stop doing the shopping. The risk for clinicians is that they might misinterpret this social withdrawal as the inevitable consequence of retirement or ageing, when it actually reflects avoidance behaviour associated with pathological anxiety. Identification of avoidance behaviour is important because avoidance makes anxiety worse, leading to its exacerbation and persistence. The persistence of avoidance behaviour in older people is often supported by well-meaning family members or carers, and sometimes by domiciliary services. Severe avoidance behaviour of the sort seen in agoraphobia almost always means that the patients have one or more supporters who help them maintain their behaviour. Even severe avoidance behaviour can be concealed for many years before coming to clinical attention, often precipitated by a change in care arrangements. Sometimes the term ‘dependency’ is used to describe the situation in which an older person is overly reliant upon others, although in many instances this should really be reframed as avoidance behaviour related to anxiety disorder.

Somatic symptoms

Older people have many more somatic symptoms than younger people due to the exponential rise in the prevalence of general medical problems with normal ageing. Older people are also thought to be more likely than younger people to minimize psychological symptoms and to convert psychological distress into physical symptoms, although it is unclear the extent to which this is a cohort effect or a direct effect of psychophysiological changes associated with ageing. It is often difficult for the clinician to disentangle the symptoms of general medical conditions from somatic symptoms of anxiety. Indeed, both types of somatic symptoms are often present simultaneously in the same person.

Obsessions and compulsions

Obsessional ruminations and compulsive rituals are core features of OCD but are also found in other mental disorders, especially major depressive disorder. Obsessional ruminations commonly involve aggressive, sexual, repugnant, immoral, or religious themes, on the one hand; or doubt, contamination, checking, superstition, symmetry, or order, on the other (Garcia-Soriano et al., 2011). They seem to exist on a continuum with intrusive thoughts experienced by individuals without OCD. The level of insight that accompanies obsessional phenomena varies, with some people with OCD believing that their intrusive thoughts will come true. In some cases of severe OCD, obsessional thoughts may be difficult to distinguish from delusions. Compulsive behaviours also appear to exist on a continuum with normal rituals and they can sometimes be difficult to distinguish from one another (Muris et al., 1997). Rituals generally involve similar themes to obsessional ruminations, and often involve washing and checking behaviours. True compulsions are generally more frequent, more intense, and associated with more affect than normal rituals. (Starcevic et al. 2011) investigated the functions of compulsions in adults with OCD and, not unexpectedly, found that compulsions are usually performed automatically to decrease stress or anxiety.

Flashbacks

During a flashback the older person re-experiences a traumatic event during the waking state, in contrast to dreams or nightmares in which this occurs whilst asleep. Flashbacks are a core component of acute stress disorder and PTSD.

Depersonalization and derealization

In depersonalization, patients feel as though they are watching themselves as if in a dreamlike state. There is a sense of unreality about the self. In contrast, in derealization, patients feel a sense of unreality about the outside world. Depersonalization and derealization are common phenomena in people with anxiety disorders, and are part of the reason that panic attacks can be associated with a sense of impending doom or the thought that one is losing one’s mind.

Anxiety Disorders

Panic disorder

To meet DSM-IV diagnostic criteria for panic disorder, panic attacks must be accompanied by at least four symptoms from a list, must peak within 10 min, and must be uncued. The practical problems with this definition are that panicky feelings are not always accompanied by the requisite four symptoms, do not always rise to a crescendo within 10 min, and are often cued by contextual factors. As a consequence, panicky episodes are more prevalent than narrowly defined panic attacks, and subthreshold panic disorder is more prevalent than panic disorder. So panic in older people is a larger clinical problem than the epidemiological data would suggest. Whilst panic attacks are the defining feature of panic disorder, they occur in many other mental disorders, including major depressive disorder, GAD, alcohol withdrawal, and delirium. Older people with panic disorder are seen in the emergency department, where panic attacks mimic a variety of medical emergencies, including asthma and acute coronary syndrome. Panic attacks and panic disorder commonly precede the development of agoraphobia.

Agoraphobia

Agoraphobia involves fear and avoidance of situations from which escape might be difficult or embarrassing, or in which help might not be available if a panic attack should occur (American Psychiatric Association, 2000). People with agoraphobia often avoid entering supermarkets, restaurants, or crowded shopping malls. They often have less trouble entering feared situations when accompanied by a trusted family member or friend. As time goes by, people with agoraphobia often gradually increase the range of situations they avoid, until they are quite limited in the situations they feel they can enter safely. People with agoraphobia tend to present for clinical care many years after the first onset of their panic attacks or avoidance behaviour. Agoraphobia is often a hidden problem in the sense that both patients and their family supporters tend to conceal it due to embarrassment.

Social phobia

People with social phobia experience fear, embarrassment, or humiliation in social situations, and experience anticipatory anxiety about forthcoming events. They avoid situations in which they feel other people may judge them. When avoidance is not feasible, they feel anxious and self-conscious around other people. Social phobia can be restricted to a certain social situation, such as public speaking, or it can be generalized. Social phobia can be precipitated by another psychiatric disorder, such as major depressive disorder or panic disorder. It is also commonly associated with substance use disorders, particularly alcohol abuse and dependence. Although social phobia is not an uncommon diagnosis in epidemiological surveys, older people with this condition rarely present for treatment. This might be because older people are not particularly disabled by social phobia due to reduced social and occupational demands in later life. There has been some controversy about the nosological status of social phobia, including concerns about medicalization of normal shyness.

Generalized anxiety disorder

As conceptualized in DSM-IV, the diagnosis of GAD requires the patient to have multiple worries that are experienced as excessive and that have persisted for 6 months or more. Older people with GAD report similar worry content to older worriers without GAD, but greater worry frequency (Diefenbach et al., 2001). This observation highlights the issue of whether GAD should be conceptualized as a dimensional disorder rather than a categorical disorder. In comparison with nonpathological worriers, those with GAD differ also in the extent to which they can control their anxiety and in the level of distress associated with their anxiety (Ruscio, 2002). Worry is the predominant symptom in GAD, to the extent that (Andrews et al. 2010) have argued that the disorder should be renamed generalized worry disorder, major worry disorder, or pathological worry disorder, in DSM-5. GAD appears to precede major depressive disorder (MDD) more often than MDD precedes GAD. Gonçalves et al. (2011) found that GAD in older people was associated with functional limitations, psychiatric comorbidity, and increased medication intake.

Specific phobia

Specific phobia involves avoidance of feared objects (e.g. spiders, moths) or situations (e.g. flying, lifts). Although specific phobia is highly prevalent, it is not often the focus of therapeutic attention in old age psychiatry practice, mainly because it is generally associated with little distress or disability, apart from when the patient is actually confronted by the phobic stimulus. Older people are often able to avoid their phobic stimuli. Some specific phobias resolve without formal treatment, but some cause significant distress and disability.

Fear of falling is a relatively distinct psychosyndrome in later life with features of both specific phobia and agoraphobia (Coelho et al., 2010). It is associated with considerable disability for many older people. At least 30% of persons aged 65 years and over fall each year and one-fifth of these falls require medical attention (Stel et al., 2004). Falls are even more prevalent in older people with dementia (Allan et al., 2009) and in those taking psychotropic medication (Hill and Wee, 2012). Approximately one-quarter of those who fall develop fear of falling (McClure et al., 2005).

Post-traumatic stress disorder

PTSD develops in about 15–20% of older people exposed to life-threatening trauma. Classically, PTSD follows combat exposure, armed holdup, rape, and violent assault. It is also seen in emergency workers required to deal with multiple trauma cases, and following disasters. In older people, PTSD has often developed earlier in life during military service, but can also develop de novo following adverse life events in later life. Sometimes PTSD does not develop immediately following exposure to the traumatic event, but following an extended delay. Characteristic symptoms of PTSD include intrusive re-experiencing of the traumatic event through flashbacks and nightmares. These intrusive phenomena are usually accompanied by hyperarousal, emotional numbness, and avoidance behaviour. Symptoms of hyperarousal include impaired concentration, lowered startle threshold, hypervigilance, and insomnia. Emotional numbness leads individuals to feel that they can no longer experience emotions normally and that their interpersonal relationships are impaired. Avoidance behaviour commonly involves avoiding the scene of the traumatic exposure or avoiding reminders of the trauma. Many other symptoms occur in PTSD, including dissociation and substance abuse. In older people, PTSD has often been present for many years following combat exposure or wartime rape and other atrocities. Older refugees are particularly at risk of PTSD. Older victims of natural disasters such as floods, fires, and earthquakes are also at risk of PTSD.

Obsessive-compulsive disorder

OCD is characterized by obsessional ruminations and compulsive rituals. Obsessions are thoughts, images, and impulses that lead to psychological distress. Patient experience obsessions as being the product of their own mind and generally have insight into them. Compulsions can be observable behaviours (rituals) or unobservable behaviours (mental compulsions). Compulsions are considered to represent an attempt by the patient to undo obsessional thoughts, prevent harm, or reduce anxiety. Although obsessions and compulsions are the defining characteristics of OCD, they do occur in other mental and neurological disorders.

Of particular relevance to OCD in older people, hoarding is often performed because of a perceived need for collected objects rather than for reasons common to other compulsions. Hoarding behaviours appear to occur commonly in the general population (Timpano et al., 2011) and are linked to compulsive buying behaviours (Mueller et al., 2009). There is also evidence that hoarding is associated with multiple neurological and psychiatric disorders, including depression and anxiety (Mataix-Cols et al., 2011; Reid et al., 2011). Hoarding also overlaps with severe domestic squalor (Snowdon and Halliday, 2011). Moral or religious scrupulosity is often viewed as a symptom of OCD. Although more commonly encountered in older members of the clergy, it can be seen among laity as well.

Mixed anxiety and depression

Some older people experience a mixture of anxiety and depressive, although the prevalence of these mixed states is in dispute. As previously noted, there is some comorbidity between GAD and major depressive disorder. In addition, there is a group of older people who experience symptoms of both anxiety and depression without meeting diagnostic criteria for a mood or anxiety disorder. The diagnostic entity of mixed anxiety and depressive disorder already exists in ICD-10 and has been proposed for DSM-5. Because of the dimensionality of both anxiety and depressive symptoms, and because mixed subthreshold states appear to be common among older people, this is a useful diagnostic category.

Anxiety and agitation in dementia

One question that arises is can anxiety be distinguished from the agitation associated with dementia? It is difficult to give a straightforward answer to this question because both anxiety and agitation are words that describe complex arrays of human behaviours. There is clearly some overlap between the constructs (Twelftree and Oazi, 2006), but also many differences between the two. The term agitation is commonly used to describe a broad range of behaviours in people with dementia. Agitation is also used to describe a category of behaviour in people with delirium and a different category of behaviour in people with depression. So the legitimate question arises, can anxiety be reliably distinguished from agitation? In a large factor analytic study of untreated patients with dementia due to Alzheimer’s disease, (Spalletta et al. 2010) found that anxiety and agitation loaded on separate factors. Anxiety loaded on a factor with depression, whereas agitation loaded on a factor with irritability and aberrant motor behaviour. Although this finding alone is unlikely to settle the matter, it does suggest that these terms should not be conflated.

Anxiety and suicide

There is robust evidence linking suicide attempts with anxiety disorders. Using data from the US NESARC study, (Nepon et al. 2010) found that among adults reporting a lifetime history of suicide attempts, 70% had an anxiety disorder. In multivariate models, PTSD and panic disorder were independently associated with suicide attempts. Individuals with PTSD or panic disorder who also had a personality disorder had an even greater risk of suicide attempts (Nepon et al., 2010).

Assessment

Every psychiatric assessment interview should include screening questions for anxiety symptoms, given the high prevalence of anxiety symptoms and anxiety disorders. At a minimum, worry, panic, obsessions, and compulsions should all be covered. It is important to be aware of limited-symptom panic attacks. These subthreshold panic attacks are characterized by fewer than the four panic symptoms required by DSM-IV definition of a panic attack. The clinician should also make specific inquiry about the nature and extent of avoidance behaviour in older people presenting with anxiety symptoms. Avoidance behaviour can manifest as ‘taking to the bed’ with nonspecific somatic symptoms, or be more subtle or camouflaged in some way, perhaps with the older person declining routine social invitations, only leaving the home in the company of others, not watching the television news, or avoiding talking about or even thinking about certain topics. As anxiety increases the risk of suicide attempts, the clinician should ensure that suicidality is covered during the assessment of older people with anxiety. Anxiety often flares up in response to adversity, so assessment of exposure to adverse life events is essential. A life-history approach is often useful to chart the correspondence between life events and anxiety symptoms. If a behavioural intervention is intended, then a behavioural analysis is a necessary preparatory step.

Informant interviews

Informant interviews are an essential component of the assessment of older people with suspected cognitive impairment or dementia. They are also useful in older people with anxiety disorders. Some older people minimize the extent of their avoidance behaviour or the relationship of this to their anxiety symptoms. An appropriate informant, usually a close family member, can often shed useful light on this avoidance behaviour. An informant can also often provide collateral information about the use of substances, including alcohol and benzodiazepines. In most countries, older people are free to consult as many different doctors as they wish. In so doing, they are at liberty to obtain multiple prescriptions for sedative and hypnotic drugs. When older people with anxiety disorders are seen in specialist settings, they have generally been referred by only one of the doctors with whom the patient has had contact. In such circumstances, an informant can provide an important insight into the drug-seeking or drug-using behaviour of the patient. Of course, consent must be obtained from the patient before consulting an informant.

Rating scales

It is often useful to measure the severity of anxiety during assessment or treatment. Many scales are available to measure anxiety in adults, but very few have been specifically designed for use in older people. Self-report scales for use by older people, particularly the frail older person, require certain modifications. Ideally, such measures should avoid multiple somatic items, reversed items, and complex response scales (Dennis et al., 2007). The Short Anxiety Screening Test (SAST) is a 10-item self-report measure with a four-item response scale (Sinoff et al., 1999). The SAST was designed specifically for use in older people, although it does contain multiple somatic items. The Geriatric Anxiety Inventory (GAI) is a 20-item self-rating scale designed to assess generalized anxiety in older people (Pachana et al., 2007b). It employs straightforward language and dichotomous (agree/disagree) ratings, and minimizes the use of somatic items. There is also a five-item version for screening (Byrne and Pachana, 2011). The GAI is now available in multiple languages.

Substance abuse

Older people with clinically significant anxiety often abuse alcohol or benzodiazepines. They frequently minimize their intake of these substances or minimize the likely link between their intake and their anxiety symptoms. Substance abuse and dependence can be the direct cause of anxiety symptoms or can be the consequence of self-medication of a pre-existing anxiety disorder. In older people with mild cognitive impairment or dementia, particularly those living alone, alcohol abuse can be unsuspected, even by members of their immediate family. In office practice, it helps to have a knowledgeable informant who can provide collateral information about substance use. A domiciliary visit can often help clarify an older person’s likely alcohol intake. Clinicians should maintain a high index of suspicion for substance abuse and dependence in older people with anxiety disorders.

Medications associated with anxiety

Many medications used to treat mental disorders and general medical conditions are associated with anxiety symptoms, and sometimes the most effective intervention is the cessation of unnecessary medication. Sympathomimetics, corticosteroids, oestrogen, antihistamines, interferon, TNF-alpha, and thyroid hormones have all been associated with anxiety symptoms. In addition, psychotropic drugs, including anxiolytics, antidepressants, mood stabilizers, and antipsychotics can cause anxiety symptoms.

Physical work-up

Older people who present with anxiety symptoms for the first time in later life should be investigated for underlying general medical problems. Even those older people who have a distant past history of anxiety symptoms but who have been symptom-free for many years should undergo screening tests for potential underlying general medical problems. At a minimum, a systems review should be undertaken and vital signs should be recorded. In first-onset cases of anxiety disorder in later life, more detailed neurological and cardiovascular examination is prudent. Selected laboratory tests, including full blood examination, serum electrolytes, serum glucose, thyroid stimulating hormone (TSH), and urinalysis should be ordered. If psychotropic medication is to be prescribed, then pretreatment liver function tests and an electrocardiogram (ECG) should be added to the list. If there is any suggestion of substance abuse then a urine drug screen should be ordered. Electroencephalography (EEG) can help exclude epilepsy and delirium, if these are suspected clinically. Neuroimaging has a low yield in late-life anxiety disorders, but if underlying cerebrovascular disease is suspected then a structural brain scan (MRI or CT) might be warranted to assess the extent of this. Serological tests for syphilis, hepatitis, HIV, and other infections should be reserved for particular cases in which the history suggests greater than normal risk. Older patients with unusual presenting symptoms should undergo more detailed physical investigation.

Management

There is actually quite a lot for the clinician to do when managing anxiety in older people. Paying close attention to some straightforward general principles is likely to greatly assist the patient, so these will be described here first. Anxiety of moderate severity or greater is likely to require formal treatment with psychological treatment, pharmacological treatment, or both. Several classes of drugs have been used in the treatment of anxiety symptoms and anxiety disorders in older people and several types of behavioural and psychological treatments have been used. A stepped-care approach may be effective in reducing or even preventing symptoms (van’t Veer-Tazelaar et al., 2009).

General measures

Substance use

Both excessive consumption of nicotine, caffeine, and alcohol and withdrawal from these substances are commonly associated with anxiety symptoms. People with anxiety disorders also self-medicate with these substances. Some older people require specific advice about minimizing their exposure to these legal substances. Medications used to treat general medical conditions may also be associated with anxiety and insomnia. These include sympathomimetics, corticosteroids, thyroid hormones, antimicrobials, oestrogen, and antihistamines. Diuretics commonly disrupt sleep and are generally best taken earlier in the day. Stimulants including methylphenidate and dexamphetamine are used occasionally to treat adult attention deficit hyperactivity disorder (ADHD) and apathy in older people. These medications are commonly associated with weight loss, insomnia, and anxiety. Some antidepressant medications have stimulant effects in vulnerable older people, and selective serotonin reuptake inhibitors (SSRIs) commonly cause an initial increase in anxiety and insomnia.

Although older people are less likely than young or middle-aged people to use illicit substances, there are cohort effects at work that might lead to increased rates of substance abuse in older people in the future (Wu and Blazer, 2011). Cannabis, amphetamine, cocaine, and opiates can all cause anxiety symptoms. Thus, a careful review of current substance use, both licit and illicit, is recommended.

General medical conditions

Many general medical conditions are associated with anxiety, either directly or indirectly. Although a direct mechanism has not been fully elucidated, it is likely to involve cytokine production at sites of inflammation. An indirect mechanism involves a psychological reaction to pain, discomfort, and disability, as well as increased dependency upon others and a sense of an altered future, associated with many diseases. Hyperthyroidism, paroxysmal supraventricular tachycardia, atrial fibrillation, asthma, chronic obstructive lung disease, epilepsy, and systemic lupus erythematosis have all been associated with anxiety disorder. Thus, optimal management of patients’ general medical conditions is an integral component of management of their anxiety disorder.

Physical activity

In older people, physical activity has general benefits for health, particularly in maintaining or improving bone density, muscle strength, and cardiovascular fitness. In addition, physical activities such as walking, cycling, and swimming have anxiolytic effects. Exposure to interoceptive stimuli, such as increased rate and depth of breathing, increased heart rate, and perspiration, acts as a form of nonspecific exposure in people with anxiety disorders. This exposure to interoceptive stimuli is associated with reduced anxiety sensitivity (Barbour et al., 2007).If the physical activity is undertaken outdoors, or in a public setting such as a gym, it also acts as exposure to exteroceptive stimuli.

Sleep hygiene

Sleep architecture changes gradually with increasing age and sleep continuity declines in many older people (Harbison, 2002). Some people interpret these normal changes as indicative of a sleep disorder, when they are not. Nevertheless, insomnia does reduce the quality of life of many older people, particularly those who suppress their REM sleep with hypnotic medication, or those who worry excessively about their sleep continuity or duration. Improvements in sleep duration and quality can lead to reduced anxiety. Routine sleep hygiene recommendations include ensuring that the sleeping environment is satisfactory. In practice, this means having a comfortable bed and pillow, maintaining the bedroom at an appropriate temperature, and ensuring the sleeping environment is both quiet and dark. It is also important to reserve the bedroom for sleep and sexual activity, and not remain in bed if unable to sleep. In this way, the bedroom is associated with sleep rather than wakefulness. It is also recommended that people with a sleep initiation problem do not undertake vigorous physical exercise in the hours immediately before bedtime, although physical exercise during the day generally assists initiation and maintenance of sleep (Loprinzi and Cardinal, 2011). Because of its potential to stimulate some people with insomnia, it is recommended that television should not be watched in the bedroom. From a behavioural perspective, it is useful to have a bedtime routine that conditions one to expect sleep.

Psychological interventions

For pragmatic reasons, psychotropic medications are commonly used as first-line treatments for anxiety disorders in older adults, particularly in primary care settings. However, expert opinion generally advises the use of a psychosocial intervention for anxiety disorders of mild to moderate severity and combination treatment with a psychosocial intervention and a psychotropic medication for more severe anxiety disorders. In old age psychiatry services, most anxiety disorders will be at least moderate in severity and will often occur in comorbid relation to other disorders, including mood disorders, psychotic disorders, and substance use disorders. Thus, combination treatment with a psychosocial and psychopharmacological intervention will generally be indicated in these specialist mental health care settings.

Therapeutic alliance

A supportive relationship with a mental health clinician is likely to be of considerable value to the anxious older person, and time spent developing a durable therapeutic alliance is well worth the investment. Psychological and behavioural interventions that provide older people with an improved set of coping skills are likely to be of enduring benefit to them. Older people with anxiety disorders are often helped by a longer-term relationship with a mental health worker. Patients who are allocated to medical personnel who move rapidly through different treatment teams as part of their training should also be allocated a case manager or staff psychologist who has a continuing appointment. In this way, continuity of care can be provided. An effective therapeutic alliance is likely to be particularly important if the clinician will be recommending to the patient either formal exposure therapy (e.g. systematic desensitization) or a reduction in avoidance behaviour. The perceived counterintuitive nature of these interventions requires patients to trust their clinicians to a greater extent than usual.

Psychoeducation

Many older people with anxiety symptoms and anxiety disorders suspect that they have serious physical problems. As a consequence, psychoeducation is an essential component of any anxiety management plan. In some cases, psychoeducation alone leads to a clinically significant improvement in anxiety symptoms as the older person reframes their problem. In people with cognitive impairment or intellectual disability it is essential that psychoeducation is provided to their family and carers.

Relaxation training

Relaxation training is an essential component of the treatment of anxiety symptoms and anxiety disorders in older people. Many different types of relaxation training have been described, although three techniques are in common use: progressive muscular relaxation, reciprocal inhibition via visual imagery, and controlled breathing. Progressive muscular relaxation is most suitable for those older people without significant sarcopenia or joint deformity, whereas the other two techniques can be used by most older people without cognitive impairment.

Cognitive behaviour therapy

There is a growing body of evidence in support of the use of cognitive behaviour therapy (CBT) to treat GAD in older people. A meta-analysis of CBT versus control conditions for GAD in older people identified 11 small clinical trials with usable data (Gonçalves and Byrne, 2012b). CBT was superior to control conditions with a pooled odds ratio of 0.33 (95% CI: 0.17–0.66). The superiority of CBT was demonstrated in those studies that used usual care or a waiting list as the comparison condition, but not in those that compared CBT to an active comparator. This observation raises questions about the specificity of CBT and suggests that other interventions could have similar efficacy. (Laidlaw et al. 2003) and Pachana et al. (2007a) have detailed suitable modifications for the use of CBT or its components in older adults. These include an increased number of sessions to allow more time for participants to develop an understanding of the therapy and its associated homework tasks, explicit learning aids, and manuals with larger print size. CBT techniques are also used in the management of several other anxiety disorders in older people, although without the same level of empirical evidence.

Behaviour therapy

In some older people with anxiety disorders, it is not practicable to implement the cognitive components of CBT. This can occur when the older person has significant cognitive impairment or intellectual disability. It can also occur when older people do not view their problem in psychological terms and remain impervious to psychoeducation. In such situations it makes sense to apply behavioural interventions alone. The principles of behavioural activation can be employed (Ekers et al., 2011; Snarski et al., 2011). These emphasize graded activity scheduling and a reduction in avoidance behaviours. In one study involving adults with major depression, behavioural activation outperformed CBT and was comparable to antidepressant medication (Dimidjian et al., 2006). There is preliminary evidence that such an approach might be applicable to older adults with anxiety disorders as well (Pachana et al., 2007a).

Exposure therapy is the treatment of choice for agoraphobia, social phobia, and specific phobia. As flooding is rarely appropriate or practicable, systematic desensitization is the usual exposure method employed. This involves the preparation of a hierarchical list of phobic cues in close consultation with the patient. The phobic cues are listed from least aversive to most aversive. Exposure tasks are then designed to enable the patient to systematically work through the list from least aversive to most aversive. An individualized approach is necessary, as the time needed to master each step will vary from patient to patient. Many patients find themselves unable to engage in exposure therapy without the assistance of a confederate. This should usually be a clinician rather than a family member, as family members often overtly or covertly sabotage exposure activities. However, the ultimate aim of systematic desensitization is for patients to be able to repeatedly expose themselves to the phobic object or situation without the assistance of another person. In OCD, compulsive rituals are generally treated with exposure and response prevention. This is an effective treatment when rigorously applied. Obsessional ruminations can be treated with either antidepressant medication or CBT, or both. Because exposure therapy does lead to a temporary increase in psychological distress, it must be undertaken with the informed consent of the patient. Deception is not part of exposure therapy for anxiety disorders.

Interpersonal psychotherapy

Interpersonal psychotherapy (IPT) uses four principal models to engage the patient. These models address (1) issues that arise in relation to grief following loss of a loved one, (2) conflict in relationships, (3) adapting to change in life circumstances, and (4) social isolation. It is not difficult to see that generalized anxiety symptoms and phobic avoidance behaviour could easily arise in relation to each of these challenges that occur commonly in later life. Despite this, there are limited data in support of the use of IPT in the management of anxiety disorders in older adults, although it is used for the management of depression in late life (Reynolds et al., 1999).

Problem-solving therapy

A reduced capacity to solve everyday problems has been linked, directly and indirectly, to anxiety. The indirect link is with impaired problem-solving and worry, which in turn lead to anxiety (D’Zurilla and Nezu, 2007: 80–81). The clinical approach to problem-solving therapy involves iterative cycles of problem definition and formulation, generation of alternative solutions through brainstorming and other techniques, and identification of the most effective solution (D’Zurilla and Nezu, 2007: 95–148). Although much of the research on problem-solving therapy has been conducted in young and middle-aged persons, or in older people with depression rather than anxiety, there has been some recent work in older adults with anxiety. In a pragmatic randomized controlled trial conducted in the Netherlands, 6 weeks of bibliotherapy involving problem-solving techniques and systematic desensitization was superior to treatment as usual in older primary care patients with an anxiety disorder but no comorbid depression (Seekles et al., 2010). In contrast, a Hong Kong clinical trial that compared brief problem-solving therapy with group viewing of health videos in primary care patients with elevated Hospital Anxiety and Depression Scale scores did not find a significant difference between treatment arms (Lam et al., 2010). There is evidence of the superiority of problem-solving therapy to supportive therapy in older people with depression (Alexopoulos et al., 2011), but further research is needed in older people with anxiety disorders in order to establish the place of PST in late-life anxiety disorders.

Other types of therapy

If anxiety symptoms arise in the context of interpersonal conflict, within a marital relationship or its equivalent, or within a family, then consideration should be given to couples therapy or family therapy. Psychoanalytic psychotherapy has been used historically to treat chronic anxiety symptoms, but not commonly in older people. There is little conventional evidence for this approach in this age group.

Medication

Drug therapy is generally unhelpful in the management of specific phobias, which usually respond to behaviour therapy, particularly exposure-based treatments employing systematic desensitization. Drug therapy does have a role in the management of the other anxiety disorders, particularly in combination with some type of psychotherapeutic intervention. A meta-analysis of clinical trials of psychotropic medication for GAD in older people identified nine brief clinical trials with usable data, including eight trials with a placebo comparator (Gonçalves and Byrne, 2012b). Medication was superior to the control condition with a pooled odds ratio of 0.32 (95% CI: 0.18–0.54). Benzodiazepines, antidepressants, and quetiapine all demonstrated short-term efficacy.

Benzodiazepines

Benzodiazepines operate at the GABAA receptors of the brain’s main inhibitory neurotransmitter GABA (γ‎-aminobutyric acid). There is crossreactivity with alcohol at this receptor complex. Benzodiazepines remain in widespread use in older people with anxiety disorders, although the evidence in support of their use is rather limited. They appear to have short-term efficacy in the management of panic attacks, generalized anxiety, and insomnia. However, their long-term effectiveness is uncertain and their use is associated with a range of adverse effects in older people, including anterograde amnesia, confusion, and falls. Tolerance develops rapidly and abrupt cessation of benzodiazepines is often associated with withdrawal phenomena. Both patients and clinicians find it difficult to distinguish benzodiazepine withdrawal phenomena from the pre-existing anxiety, thus perpetuating the use of these agents. Benzodiazepines suppress REM sleep (Hemmeter et al., 2000) and rebound effects can be encountered following their withdrawal. Withdrawal phenomena appear most severe following long-term use of high doses of short-acting agents. A small proportion of older people prescribed benzodiazepines develop paradoxical effects such as excitement or agitation. When benzodiazepines are used in the management of anxiety symptoms, including insomnia, they should ideally be used for short periods (2–4 weeks) whilst other treatments are introduced. Drugs such as oxazepam and temazepam, which do not undergo hepatic oxidation, are generally preferred in older people. Because of its slow rate of absorption, oxazepam is useful for the treatment of middle insomnia, whereas temazepam is more useful for initial insomnia. Modern benzodiazepine replacements such as zopiclone and zolpidem have similar pharmacological properties to the benzodiazepines and seem to confer few advantages. Although the benzodiazepines have short-term efficacy in many of the anxiety disorders, they are considered ineffective in OCD and of limited value in PTSD.

Antidepressants

Antidepressants are preferred for the pharmacological treatment of the anxiety disorders, although their use in this context does have some challenges. The SSRI antidepressants are the usual first-line medications in older people with panic, social phobia, GAD, OCD, and PTSD. They appear to be of no value in specific phobia. SSRIs take effect much more slowly than benzodiazepines, with longer-term effects on the sensitivity of autoreceptors leading to increased availability of synaptic 5-HT. The SSRIs are commonly associated with an initial increase in tremor, insomnia, and anxiety, and anxious older patients should be warned about this, lest they become concerned that their underlying disorder is deteriorating. It is sometimes necessary to use a low-dose benzodiazepine for a week or two to get the patient through the initial adverse effects of an SSRI, particularly in somatically focused patients. A greater challenge for prescribers is that patients who have had experience with the rapid onset of action of the benzodiazepines are often dissatisfied with the relatively slow onset of action of antidepressants. There appears to be little to choose between the available SSRI antidepressants in terms of their anxiolytic effects. However, paroxetine has more anticholinergic effects than the other drugs in this class and for this reason is generally less favoured in older people. The long half-life of fluoxetine is associated with both risks and benefits, but fluoxetine is generally not the first choice in older people. Citalopram and escitalopram are associated with prolongation of the electrocardiographic QTc interval and it has been recommended that they be restricted to 20 mg and 10 mg daily, respectively, in older people (Medicines and Healthcare Products Regulatory Agency, 2011). Fluvoxamine is a sedating SSRI, which is often well tolerated in anxious individuals, although it does have a greater potential for drug–drug interactions than the other drugs in its class due to effects on the hepatic enzyme system.

The SSRIs have significant adverse effects in older people. These include initial worsening of anxiety and insomnia, hyponatraemia, sexual dysfunction, and falls. They are also associated with increased bruising and bleeding in patients on anticoagulants and antiplatelet drugs. Hyponatraemia occurs most commonly in women on thiazide diuretics, and often within 6 weeks of initiating antidepressant treatment. The symptoms of hyponatraemia can mimic those of worsening anxiety or depression, and can also include fatigue and confusion. The true prevalence of hyponatraemia is unknown but it is a frequent occurrence on inpatient wards. The clinician is advised to check the serum sodium in older patients on antidepressant medication whose clinical condition is deteriorating. All antidepressants can precipitate mania and hypomania in vulnerable individuals, but this is relatively uncommon and is not a reason to avoid these drugs in older people with clinically significant anxiety. The reported increased risk of suicide in patients commenced on SSRI antidepressants does not seem to be relevant to older people, in whom treatment with SSRIs is associated with a reduced suicide risk (Barbui et al., 2009).

Other classes of antidepressants, including the serotonin and noradrenaline receptor inhibitors (e.g. venlafaxine, desvenlafaxine, duloxetine), drugs with mixed receptor activity (e.g. mirtazapine), and the older tricyclic drugs are also used in the pharmacological management of anxiety in older people. Among the tricyclic antidepressants, nortriptyline appears to have the best safety profile in older patients. Historically, clomipramine has had a special place in the treatment of severe OCD, although its adverse effect profile makes it challenging to use in many older people. However, it is not entirely clear whether clomipramine is superior to intensive exposure and response prevention (Foa et al., 2005). The noradrenaline reuptake inhibitor reboxetine and the older, irreversible, monoamine oxidase inhibitor drugs are not usually used in the management of anxiety disorders in older people. The serotonin antagonist and reuptake inhibitor (SARI) trazodone does have anxiolytic effects, but it is not well studied in older people with anxiety disorders.

The 5HT1A receptor partial agonist buspirone has been used in treatment of GAD in older people for many years. It has a slow onset of action and seems to be most useful in benzodiazepine naïve patients. It has a number of drug–drug interactions and should not be used by people who are currently taking or who have recently been taking monoamine oxidase inhibitors. Agomelatine is an antidepressant with melatonergic (MT1, MT2) receptor agonist and 5-HT2C receptor antagonist properties that appears to reduce sleep latency without causing daytime drowsiness. There is some limited evidence for its efficacy in GAD in adults (Stein et al., 2008), but there have been no clinical trials for this indication in older people.

In older people, antidepressants are generally commenced at half the usual starting dose used in younger adults and the dose is titrated upwards more slowly. Sometimes the final antidepressant dose is lower than that used in younger people, although many older people require the same final doses as younger people to achieve efficacy. As a broad generalization, the antidepressant dose required to treat anxiety disorders is often the same or greater than that required to treat depression.

Antipsychotics

Atypical antipsychotic drugs, particularly quetiapine and risperidone, are sometimes used in the management of the symptoms of both GAD and PTSD in adults. However, evidence for the use of antipsychotics for these indications in older adults is meagre (Ahearn et al., 2011; Gonçalves and Byrne, 2012b). Cerebrovascular adverse events (strokes and transient ischaemic attacks) and excess mortality have been described in association with the use of antipsychotic medication in older nursing home residents with dementia complicated by behavioural and psychological symptoms (Sacchetti et al., 2010), although a case-control study conducted in patients with dementia in the primary care setting did not identify similar problems (Laredo et al., 2011). Nevertheless, it would seem prudent to minimize the use of antipsychotic medication in older people with nonpsychotic disorders in the absence of long-term efficacy and safety data.

Anticonvulsants

There is some evidence for the use of anticonvulsants in adults with anxiety disorders, including the use of gabapentin in social phobia, lamotrigine in PTSD, and pregabalin in social phobia and GAD (Mula et al., 2007). However, there is a scarcity of evidence relating specifically to the use of anticonvulsants in older people with anxiety disorders.

Other drugs

Lithium carbonate is rarely used for the treatment of anxiety disorders, apart from when it is used to augment other agents that are being used to treat comorbid disorders. Lithium is not recommended for the treatment of older people with anxiety disorders. Beta-adrenergic blockers, principally propranolol, have been used to reduce performance-related tremor in musicians. Clonidine has been used to assist in the management of preoperative anxiety.

Conclusion

Anxiety disorders occur commonly in older people and are associated with considerable emotional distress and disability. Anxiety disorders in later life tend to be both underdiagnosed and undertreated. Anxiety disorders are often seen in comorbid relation to other mental disorders and to general medical conditions. Effective treatments exist for anxiety disorders, although greater effort is needed to make these treatments routinely accessible to older people, including those with physical frailty or cognitive impairment.

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