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J Am Board Fam Pract: first published as 10.3122/jabfm.10.4.280 on 1 July 1997. Downloaded from CLINICAL REVIEW Disorders in Elderly Patients

Deborah A. Banazak, DO

Background: Late-life anxiety disorders, commonly seen in primary care settings, can coexist with other medical and psychiatric illnesses. A variety of effective treatment options is available for these patients. lI-lethods: l\IEDLINE was searched for articles published from 1970 to 1996 using the key words "anxiety," "elderly," "aged," "geriatric," "," "obsessive-compulsive," "," and "generalized ." Studies of patients older than 65 years were reviewed. Results: Generalized anxiety disorder, , , and obsessive-compulsive disorder are the most common late-life anxiety problems seen by primary care physicians. Patients with these disorders complain of diffuse multisystem symptoms, motor restlessness, and such physiologic symptoms as or tachypnea. Comorbid illnesses include depression, alcoholism, use, and multisystem disease. Behavioral strategies to address anxiety include an open discussion of the issue, an anxiety diary, psychosocial support, and cognitive-behavioral techniques. Pharmacologic strategies include carefully monitored , , or therapy. Conclusions: Clinical trials of all anxiety interventions are needed for elderly primary care patients to clarify further whether findings from mixed-age population studies are generalizable to the elderly. (J Am Board Fam Pract 1997;10:280-9.)

Caring for an anxious elderly patient can be a medical causes and treatments for anxiety. Finally, challenge for the primary care physician. The dis­ treatment literature (including all case report and tress experienced by such patients can overwhelm double-blind study data) was reviewed to summa­ already strained families, caregivers, and commu­ rize nonpharmacologic and pharmacologic anxi­ nity support systems. Accurately diagnosing the ety treatment interventions. source of the anxiety and providing appropriate, http://www.jabfm.org/ effective treatment are critical for quality of life Epidemiologic Studies and health maintenance. Prevalence Anxiety in elderly patients is a state of hyperalert­ Methods ness in which excessive autonomic arousal results MEDLINE was searched for articles published in diminished patient coping strategies. Anxiety from 1970 to 1996 using the key words "anxiety," becomes manifest in both subjective and objective on 30 September 2021 by guest. Protected copyright. "elderly," "aged," "geriatric," "panic," "obsessive­ ways. Subjectively patients might describe uneasi­ compulsive," "phobia," and "generalized anxiety ness, , , or unrealistic apprehension. On disorder." Studies of patients older than 65 years the other hand, patients might also complain of were reviewed. Additional studies were selected somatic symptoms and be unaware they are anx­ from article references. Epidemiologic literature ious. Objective symptoms to monitor include was studied using clinical and diagnostic cate­ sweating, muscle tension, tachycardia, facial gri­ gories according to the Diagnostic and Statistical macing, restlessness, and pacing. Manual ofMental Disorders: DSM-I0 A survey of Ten to 20 percent of older patients experience the medical literature provided a summary of clinically important symptoms of anxiety.2 In an elderly community-dwelling population of the Duke Epidemiologic Catchment Area, Blazer Submitted, revised, 13 March 1997. et all found that the 6-month incidence for all From the Department of , Michigan State Univer­ anxiety disorders was 19.7 percent. In Flint's syn­ sity, East Lansing. Address reprint requests to Deborah A. Ba­ 4 nazak, DO, Department of Psychiatry, Michigan State Univer­ thesis of eight surveys consisting of community­ sity, B-109 West Fee Hall, East Lansing, MI 48824-1316. dwelling elders, the following ranges in preva-

280 JADFP July-August 1997 Vol. 10 No.4 J Am Board Fam Pract: first published as 10.3122/jabfm.10.4.280 on 1 July 1997. Downloaded from lence emerged: all anxiety disorders, 0.7 to 18.6 Table 1. Psychiatric Sources of Anxiety. percent; phobic disorder, 0.7 to 10 percent; gen­ Disorder Symptolll SUllllllary eralized anxiety disorder, 0.7 to 7.1 percent; ob­ sessive-compulsive disorder, 0.1 to 0.6 percent; Anxiety caused by a recent stressor and panic disorder, 0 percent. In community­ with anxiety based studies generalized anxiety disorder and Generalized anxiety Diffuse constant anxiety and disorder worry phobias are the most common forms of anxiety in Obsessive-compulsive Intmsive thoughts and repetitive elders, although and obsessive-com­ disorder behaviors pulsive disorder might occasionally occur de novo Panie disorder Episodic overwhelming anxiety and in late life.4 autonomic signs These low rates are deceiving because of psy­ Phobias Agoraphobia Fear of being trapped in a place chiatric comorbidity. When elderly patients have from which escape might be symptoms of depression, 33 percent also have difficult and anxiety might occur considerable comorbid anxiety.s In an elderly co­ Social phobia Fear of social embarrassment hort, Ben-Arie and colleagues6 found a high cor­ Fear of specific object or situation relation between panic disorder and depression. Posttraumatic Traumatic event reexperienced, disorder creating anxiety Treatment for these patients' conditions con­ sisted largely of benzodiazepine therapy, which neglected their depression and its contribution to and worries, such as the fear of robbery, anxiety symptomatology. falls, or strangers, phobias are considered irra­ Determining the source of anxiety can be a tional fears of a specific object or situation. If a clinical challenge. In late life anxiety can be pre­ worry becomes so incapacitating that it causes ir­ cipitated by losses-such as loss of health, mobil­ rational avoidance behaviors and high levels of ity, financial status, lifelong partners, and support distress, it may be considered a phobia. In pri­ systems-and fears of losses. Brief anxiety reac­ mary care settings, up to 7 percent of patients tions that do not impair ongoing coping abil­ older than 65 years can have phobias.s ities should be considered normal. Nervousness The new onset of panic disorder in late life is that consistently impairs the senior's life and rare.4 Panic disorder is most often a preexisting becomes functionally overwhelming, however, is condition associated with other medical or psychi­ pathologic. atric conditions. Raj et al9 studied an elderly com­ http://www.jabfm.org/ Some authors categorize anxiety as primary munity-dwelling population and found that and secondary,7 in which primary anxiety results patients with panic disorder also had chronic pul­ from psychiatrjc conditions, and secondary anxi­ monary disease, , and Parkinson disease. ety has a medical cause. In the Diagnostic and Sta­ They also found high rates of depression (40 to 52 tistical Manual ofMental Disorders: DSfvl-IV, 1 sec­ percent) in these patients. In mixed-age primary ondary anxiety has been relabeled as anxiety care settings, KatonlO found that 6 percent of pri­ on 30 September 2021 by guest. Protected copyright. disorder caused by a general medical condition. mary care patients exp~rienced panic disorder. Distinguishing between psychiatric and medical Generalized anxiety disorder is common in late causes is especially-difficult in the older patient, as life and accounts for up to 50 percent of all anxi­ comorbid medical and psychiatric conditions al­ ety in this population.4 In primary care settings, most always exist. generalized anxiety occurs in up to 10 percent of patients older than 65 years.s Because this anxiety Psychiatric Sources ofAnXiety is often unrelenting, caring for such patients can Table 1 summarizes the DSM-IV anxiety disor­ challenge the family and physician. Instructing a der categories with disorder-specific symptom patient not to worry is fruitless and can frustrate clusters for each diagnosis. Generally, these clus­ all involved. ters include physiologic symptoms, intense inter­ Obsessive-compulsive disorder is a lifelong dis­ nal discomfort, situationally focused fears, or re­ order that rarely starts in old age. 3 In the elderly current obsessive worries with anxiety-relieving population obsessive-compulsive disorder is more repetitive behaviors. The degree of anxiety varies common among institutionalized women than in with each disorder. While elders can have realistic other community-based populations.4 Obsessions

Anxiety Disorders in Elders 281 J Am Board Fam Pract: first published as 10.3122/jabfm.10.4.280 on 1 July 1997. Downloaded from

Table 2. Medical Conditions Associated With Anxiety. when the condition began and whether such episodes are recurrent can help determine the System Medical Condition cause. As most primary anxiety disorders have Cardiovascular Angina their origins earlier in life, a history of recurrent Arrhythmia episodes would suggest to the clinician a primary anxiety disorder. Clarifying how the illness came Endocrine mellitus IIypercalcemia about and in what order symptoms occurred can ' help. A medical illness that might have caused IIypocalcemia IIypothyroidism physical before anxiety be­ came a problem can lead the physician to suspect Gastrointestinal Pancreatic tumor that the medical illness is driving the anxiety Peptic ulcer disease symptoms. A family history is also helpful be­ Genitourinary Urinary tract infection cause panic disorder can be inherited.13 A patient Immunologic Carcinoid syndrome who complains of anxiety and who has no family Systemic lupus erythematosus or earlier life history of such disorder could have Metabolic Ilyperkalemia a medical illness as the source of anxiety. Hyponatremia Mter a thorough medical history and drug and Porphyria inventory, the patient should have a men­ Neurological tal status evaluation to assess cognitive and per­ Parkinson disease ceptual abilities as well as a complete physical ex­ disorder Tumor amination. Symptom-focused laboratory studies, Pulmonary Chronic obstructive pulmonary including urinalysis; glucose, electrolytes, disease and thyroid-stimulating measurements; Hypoxemia Pneumonia and a complete blood count will help pick up any Pulmonary embolus medical illnesses that might cause anxiery: If the patient gives a poor history and there is evidence of drug toxicity, he or she should be screened for in nursing facility patients can manifest as rigidity . Pulse oximetry provides helpful informa­ about , excessive toileting needs, and tion about hypoxemia-driven agitation. Patients

overwhelming demands upon the nursing staff. who have cardiac symptoms associated with anxi­ http://www.jabfm.org/ Anxiety disorders can also coexist with depres­ ety should have an electrocardiogram. sion. Parmelee et alii found that in elderly pa­ tients with generalized anxiety disorder, 60 per­ Medical Illnesses and Reversible Anxiety cent also had major depression. Ben-Arie et al6 Some medical conditions can cause anxiety symp­ noted that depressed patients had a much higher toms, and if the condition is addressed, the anxiety likelihood of coexisting generalized anxiety. might abate. Table 2 lists specific medical illnesses Blazer and colleagues l2 observed longitudinally a that are associated with anxiety. Likewise, Table 3 on 30 September 2021 by guest. Protected copyright. cohort of depressed middle-aged and elderly suggests a number of drugs that can cause anxiety. adults and found that those with persistent anxi­ Patients with pulmonary problems, such as ety symptoms also had incomplete recovery from chronic obstructive pulmonary disease (COP D) depression. Because physicians might recognize or asthma, can experience hypoxia as an anxiety anxiety symptoms but fail to diagnose the under­ symptom. Hypercapnia associated with COPD lying depression, the actual anxiety catalyst (the leads to increased locus caeruleus stimulation, a patient's depression) is neglected. possible noradrenergic mechanism for anxiety episodes in susceptible patients.14 Restoring ven­ The Medical Evaluation tilation and - balance can It is important to separate medical from psycho­ eliminate the anxiety. IS logical factors when evaluating anxiety in an older Hyperthyroidism can mimic panic disorder patient. A critical first step is a thorough patient without any other accompanying physical symp­ history. In addition to noting the patient's clinical toms and can be associated with nervousness, ex­ signs and symptoms, obtaining information about citability, irritability, pressured speech, or a fear of

282 ]ADFP July-August 1997 Vol. 10 No.4 J Am Board Fam Pract: first published as 10.3122/jabfm.10.4.280 on 1 July 1997. Downloaded from impending death.16 Assessment of thyroid func­ Table 3. Drugs Associated With Anxiety. tions in an anxious patient might show elevations Systcm 1YpeofDrug in thyroxine and and decreased thyroid-stimulating hormone levels. By treating Cardiovnsculnr Antihypertensivc thyroid conditions, the physician can treat anxiety Calcium Digitalis symptoms. Endocrine Although rare, pheochromocytoma can cause Thyroid major anxiety symptoms. In patients with Musculoskeletal Analgesic pheochromocytoma, sustained is Muscle relaxant Nonstcroidal anti-inflammatory often accompanied by paroxysmal , Neurologic, psychiatric Antidepressant sweats, hypermetabolic states, and evidence of Levodopa such associated conditions as neurofibromatosis Neuroleptic or medullary cancer of the thyroid. 17 Anxious pa­ Otolaryngologie Antihist.ll11ine tients should be tested for pheochromocytoma if Pscudoephedrine Pulmonary Bronchodilator they have these symptoms or are consistently un­ Steroid responsive to psychiatric interventions. Diag­ Theophylline nostic studies for pheochromocytoma include a 24-hour assay for catecholamine, meta­ nephrine, and vanillylmandelic acid. atric management to address both conditions. Drug toxicity and withdrawal are common Dementia is one example. Throughout their ill­ causes of reversible anxiety symptoms (Table 3). ness patients with dementia can suffer from agita­ Alcoholism often coexists with anxiety. Although tion, including pacing, , panic attacks, alcohol abuse or dependence does not automati­ and perceptual disturbances.2o Management cally increase the risk of anxiety disorders in el­ strategies can include behavioral techniques and derly patients, they might self-medicate anxiety or therapies.19,21 symptoms with alcoho1.4 Stockwell et aps suggest Pulmonary embolus, angina, and arrhythmia that alcohol abuse and withdrawal have a kindling are cardiovascular conditions associated with anx­ effect on the sympathetic nervous system and iety disorders. 14 In addition, prime the brain for a later anxiety disorder. has been strongly connected witll panic attacks.22

Caffeine, anticholinergic found in Seizure disorders, including temporal lobe http://www.jabfm.org/ cold and allergy preparations, and bronchodilators , are associated with motor restlessness, are among the substances that can induce anxiety. irritability, and personality change.14 Patients can Antipsychotic p1edications and reuptake experience an of impending doom. Treat­ inhibitor can precipitate , ment for these conditions includes standard med­ a of internal restlessness. 19 Withdrawal ical and psychiatric co-management of each dis­ from sedative hypnotics can cause anxiety and in­ ease process. on 30 September 2021 by guest. Protected copyright. somnia symptoms for the elderly patient.2 Another reversible source of anxiety is delir­ Treatment ium. This acute change in mental status, with Although few large double-blind studies have fo­ perceptual distortions and alternating levels of cused specifically upon older adults, case reports consciousness, can have prominent anxiety symp­ and case-controlled studies have shown that cog­ toms. Patients can become verbally and physically nitive-behavioral therapies can be effective for aggressive with each episode. By medically treat­ older patients.23 Behavior therapy, using progres­ ing the source of the delirium (Tables 2 and 3), sive muscle relaxation and breathing exercises,2'+ the physician can completely relieve patients' token economies,25 and ,26 anxiety and restore their sensorium. has also been successful with elders. With cogni­ tive therapies patients learn to challenge tlle neg­ Medical Illnesses Associated With ative thinking patterns tllat precipitate or exacer­ Comorbid Anxiety Disorders bate anxiety. Treatment in any case should be Some medical illnesses associated with anxiety patient-specific and include frequent follow-up of disorders require ongoing medical and psychi- anxiety symptoms.

Anxiety Disorders in Elders 283 J Am Board Fam Pract: first published as 10.3122/jabfm.10.4.280 on 1 July 1997. Downloaded from

Please record each anxiety episode on the following chart. Use one line for each separate episode of anxiety. Rate your anxiety level, what happened before the anxiety began, how you felt, and what you thought about during the episode. Please bring this chart with you to your next doctors appoinonent.

Events Occurring Before Physical Fears, Worries, Date Time Anxiety Level* Anxiety Episode Sensations Thoughts Emotions Felt

*On a scale from 1-10, where 1 =none and 10 =worst.

Figure 1. Anxiety diary.

Cognitive Strategies ognized stressors and clarify the negative think­ Cognitive therapy works by exploring and chal­ ing processes that are often associated with anxi­ lenging patients' misperceptions and fears. Anx­ ety. For example, if a patient had a panic attack ious patients commonly worry about negative and noted that the physical sensations of panic evaluation, rejection, failure, or losing control. (tachycardia and tachypnea) caused him to believe When challenging negative thoughts associated death was pending, pointing out that death did with anxiety, asking how others would view the not occur challenges this negative thinking. Pa­ patient, exploring the patient's own unrealistic tients often fear intense physical symptoms, standards, and pointing out all-or-nothing think­ thereby fueling more anxiety. ing are all helpful anxiety-reducing strategies. It is crucial that physicians review patient di­ http://www.jabfm.org/ Although some physicians are concerned that aries after 1 to 2 weeks of data are collected so asking patients directly about their problems will they can learn about their patients' anxiety. It is intensify their anxiety and worsen the problem, important to reassure patients that anxiety is self­ most often this response is not the case. Families limited, that the negative thinking associated with and support systems should promote open discus­ anxiety is illogical, and that nervousness will not sion of the stressors a patient faces. Physicians automatically lead to insanity or death. must be prepared to make efficient use of their on 30 September 2021 by guest. Protected copyright. office time with the patient, however, as dis­ Relaxation, Distraction, and Role Playing cussing anxiety can increase time demands in an Several behavioral techniques, including relax­ already busy practice. Nevertheless, giving pa­ ation therapy, distraction, role playing, rehearsal, tients an opportunity to talk about their worries and modeling, can help an anxious elder. Relax­ in a safe environment is therapeutic, and referral ation tapes and books (Table 4) describe progres­ for additional therapy would be helpful for in­ sive muscle relaxation, guided imagery, and sightful patients. breathing exercises. Tapes provide a calming voice to guide the listener through muscle relax­ Behavioral Strategies ation. Guided imagery tapes and books ask the Diary Keeping listener or reader to create a relaxing mental pic­ Ask patients to keep a diary of their anxiety levels ture and focus upon its calming nature. Finally, (Figure 1). By rating their anxiety several times breathing exercises break the tachypneic respira­ each day and noting all their symptoms and tory cycle with slow inhalations and exhalations. thoughts, patients can expose previously unrec- Each technique must be practiced while the pa-

284 JABFP July-August 1997 Vol. 10 No.4 .... J Am Board Fam Pract: first published as 10.3122/jabfm.10.4.280 on 1 July 1997. Downloaded from tient relaxes ~o it becomes automatic and readily Table 4. Tapes and Books To Decrease Anxiety. accessible when anxiety strikes. Using distraction techniques to shift attention Rehtxation tapes I Ia~ I louse, 1154 E. Dominf.,'1.les Street, PO Box 62(H, to a routine task can help some patients deal with Carson, CA 90749-6204. 1-HOO-645-5126. anxiety. Examples are focusing on all of the de­ I lealing Visions, Whole Person Associates, 210 West Mit:higan, Duluth, MN 55H02-1908. 1-800-247-67H9. tails of a given object, counting back from 100 in Intrinsic Development, Inc, 410 East Main Street, serial 7s, remembering a pleasant experience, or Mechanicsburg, PA 17055. 1-800-354-2858. finding a pleasurable activity that completely ab­ SOURCE, PO Box W, St

Anxiety Disorders in Elders 285 ... J Am Board Fam Pract: first published as 10.3122/jabfm.10.4.280 on 1 July 1997. Downloaded from Table 5. Pharmacologic Management of Anxiety.

Drug Dose Indications Adverse Reactions

Azapirone Buspirone (BuSpar) 5-15 mg every 8 h Generalized anxiety , , disorder ~- agents (Inderal) 10 mg every 6 h Sympathetic symptoms I Iypotension, bradycardia associated with panic disorder, social phobia Benzodiazepines Lorazepam (Ativan) 0.25-1.0 mg every 4-6 h Panic disorder, generalized Sedation, confusion, Oxazepam (Serax) 10-20 mg every 8 h anxiety disorder A1prazolam (Xanax) 0.25-1.0 mg every 4-6 h Anxiety associated with obsessive-compulsive disorder/social phobia Selective serotonin reuptake inhibitors (Prozac) 10-40 mg/d Obsessive-compulsive Activation, headache, nausea, (Luvox) 50-200 mg/d disorder, panic disorder, , hypertension (Paxil) 1O-40mg/d social phobia (2010ft) 25-200 mg/d (Effexor) 25-225 mg/d antidepressants (Anafranil) 1O-150mg/d Panic attack, agoraphobia, Sedation, orthostasis, (Norpramin) 25-200 mg/d panic disorder, obsessive­ constipation, delirium (Tofranil) 25-200 mg/d compulsive disorder (pamelor) 25-250 mg/d

pendency and greater rebound associated with ~-Adrenergic Drugs withdrawaI.29 If patients need long-term anxiety ~-Blockers work to reduce anxiety by inhibiting management, switching them to an antidepres­ brain (X- and ~-adrenergic receptors, resulting in sant or buspirone will provide a safer strategy. diminished noradrenergic stimulation. Peripheral effects are lowered blood pressure, pulse, and au­ Buspirone tonomic arousal, which cause a subjective feeling Buspirone treats generalized anxiety disorder and of reduced anxiety. ~-Blockade is most effective anxiety associated with general medical condi­ centrally. Propranolol, which is highly lipo­ http://www.jabfm.org/ tions. Robinson et apo studied 800 elderly pa­ philic and easily transported across the blood­ tients with generalized anxiety disorder for whom brain barrier, is the most frequently prescribed buspirone was prescribed and found drug efficacy ~-blocker.19 comparable to that found in younger populations. Although no clinical trials of ~-adrenergic Buspirone has not been shown to be effective for agents exist exclusively for patients older than 65 H panic disorder, phobias, or obsessive-compulsive years, Petrie and Ban noted in two case reports on 30 September 2021 by guest. Protected copyright. disorder. Because it is nonhabituating and does that propranolol diminished anxiety in several el­ not cause withdrawal symptoms, buspirone has derly demented patients, a group that might be less potential for abuse. 31 In addition, it causes considered a target population. ~-Blockers should less sedation, psychomotor slowing, and pul­ be prescribed with caution for elderly patients be­ monary impairment than do benzodiazepines3o cause of associated orthostasis and bradycardia. and is helpful for patients with generalized anxi­ ety disorder who are prone to falls, confusion, or Antidepressants chronic disease. Buspirone should be started Antid~pressants effectively treat obsessive-com­ at 5 mg three times a day and gradually increased pulsive disorder, panic disorder, and social pho­ by 5-mg increments every 2 to 5 days to a maxi­ bias. Selective serotonin reuptake inhibitors mum dosage of 60 mg/d. Patient reassurance and (SSRIs) are antidepressants with few side effects, careful encouragement might be necessary with which makes them appealing for many older buspirone, as it can take 6 to 8 weeks to become adults, even those with severe comorbid cardio­ effective32 (Table 5) .. vascular illness. Because of the interaction be-

286 JABFP July-August 1997 Vol. 10 No.4

- · •.~"~"'n ______J Am Board Fam Pract: first published as 10.3122/jabfm.10.4.280 on 1 July 1997. Downloaded from tween cytochrome P-450 and drug , be given tricyclic antidepressants because these caution should be used when combining SSRIs medications can cause a prolonged QRS complex. with tricyclic antidepressants, antiarrhythmics, All elderly patients should have a premedication codeine, , benzodiazepines, and ~­ electrocardiogram as well as serial electrocar­ blockers or calcium channel blockers. Blood lev­ diograms throughout treatment to monitor for els of these medications can increase when SSRIs increased blockade. Zitrin et al 43 studied 111 are added to a patient's regimen, and patients mixed-age patients who received should be observed carefully for clinical eVidence and imipramine therapy; they found that imipra­ of toxicity.34 mine was superior to placebo, and up to 86 per­ For obsessive-compulsive disorder, fluoxetine cent of all patients showed moderate to marked and fluvoxamine have been shown to be effective global improvement. In a series of 9 adult pa­ in clinical trials that have included some older tients, Rifkin et al44 reported that imipramine and adult patients. Feighner35 studied several hun­ desipramine prevented sodium lactate-induced dred geriatric patients treated with fluoxetine, panic attacks in all patients. Because of their anti­ noting significant decreases in Hamilton-D cholinergic side effects (sedation, confusion, con­ scores after 6 weeks. In a 20-week double-blind stipation) and a-adrenergic blockade (orthosta­ study of fluvoxamine versus placebo, Perse36 sis), tricyclic antidepressants require careful found that 81 percent of patients responded to monitoring. Blood level measurements of imip­ fluvoxamine compared with 19 percent to ramine, desmethylimipramine, and nortriptyline placebo. can help guide drug dosage.45 Although not formally approved for panic dis­ The clomipramine has order by the Food and Drug Administration been approved by the FDA to treat obsessive­ (FDA), paroxetine and venlafaxine have been ef­ compulsive disorder. Although older patients can fective in mixed-age populations. In a double­ be more vulnerable to clomipramine's anticho­ blind British study, Oehreberg et aP7 found that linergic side effects, Austin and colleagues46 re­ with 12 weeks of treatment the mixed-age cohort ported a series of 3 elderly patients, all of whom had a 50 percent reduction in the total number of had good clinical responses to this drug. panic attacks. Likewise, Geracioti38 noted that, in For patients who do not respond to initial anxi­ a mixed-age case report series, panic attacks were ety interventions, referral to a spe­ cialist should be considered. A consulting psychi­ completely eliminated in 4 patients. http://www.jabfm.org/ Initial clinical trials have concluded that SSRIs atrist can help confirm the diagnosis as well as can minimize social phobic symptoms in mixed­ offer unconsidered treatment options. Ongoing age populations. Katzelnick et a139 enrolled 12 so­ therapy can help the elder to regain self-esteem. cially phobic patients in a double-blind trial of sertraline versus placebo; they found that after 10 References weeks 50 percent of the patients taking sertraline 1. Diagnostic and statistical manual of mental disor­ reported lessened anxiety compared with 9 per­ ders: DSM-rv. 4th ed. Washington, DC: American on 30 September 2021 by guest. Protected copyright. cent taking a placebo. In an open-label venlafax­ Psychiatric Press, 19~4. ine study of 8 mixed-age patients who had social 2. Hocking LB, Koenig HG. Anxiety in medically ill older patients: a review and update. Int] Psychiatry phobias, Kelsey40 "reported that 75 percent had Med 1995;25:221-38. subjective improvement. Van Ameringen et al,41 3. Blazer DG, George LK, Hughes D. The epidemiol­ in a study of 16 patients with social phobia, noted ogy of anxiety disorders: an age comparison. In: symptom improvement in the majority of pa­ Salzman C, Lebowitz BD, editors. Anxiety disorders tients taking fluoxetine in doses of 20 to 80 mg/d. in the elderly: treatment and research. New York: Finally, van Vliet and colleagues42 prescribed flu­ Springer, 1990. voxamine for 30 mixed-age patients and found 46 4. Flint A]. Epidemiology and comorbidity of anxiety percent had substantial improvement in social disorders in the elderly. Am ] Psychiatry 1994j 151:640-9. and anticipatory anxiety. 5. Regier DA, Narrow WE, Rae DS. The epidemiol­ Tricyclic antidepressants have been used in the ogy of anxiety disorders: the Epidemiologic Catch­ treatment of panic disorder. Patients with in­ ment Area (ECA) experience. ] Psychiatr Res complete or complete heart block should not 1990j24(SuppI2):3-14.

Anxiety Disorders in Elders 287 J Am Board Fam Pract: first published as 10.3122/jabfm.10.4.280 on 1 July 1997. Downloaded from 6. Ben-Arie 0, Swartz L, Dickman B]. Depression in 23. Clark DM, Salkovskis PM, Chalkley A]. Respiratory the elderly living in the community. Its presentation control as a treatment for panic attacks. ] Behav and features. Br] Psychiatry 1987;150:169-74. Ther Exp Psychiatry 1985;16:23-30. 7. Cassem Ell. Depression and anxiety secondary to 24. Holland]C, Morrow GR, Schmale A, Derogatis L, medical illness. Psychiatr Clin North Am 1990; Stefanek M, Berenson S, et al. A randomized clinical 13:597-612. trial of alprazolam versus progressive muscle relax­ 8. Oxman TE, Barrett]E, Barrett], Gerber P. Psychi­ ation in cancer patients with anxiety and depressive atric symptoms in the elderly in a primary care prac­ symptoms.] Clin Oncol 1991 ;9: 1004-11. tice. Gen Hosp Psychiatry 1987;9:167-73. 25. Mishara BL. Geriatric patients who improve in to­ 9. 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