Anxiety Disorders in Elderly Patients

J Am Board Fam Pract: first published as 10.3122/jabfm.10.4.280 on 1 July 1997. Downloaded from CLINICAL REVIEW Anxiety 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," "panic," "obsessive-compulsive," "phobia," and "generalized anxiety disorder." Studies of patients older than 65 years were reviewed. Results: Generalized anxiety disorder, phobias, panic 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 tachycardia or tachypnea. Comorbid illnesses include depression, alcoholism, drug 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 benzodiazepine, buspirone, or antidepressant 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, worry, fear, 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 Psychiatry, 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; Adjustment disorder 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 agoraphobia 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 Specific phobia Fear of specific object or situation relation between panic disorder and depression. Posttraumatic stress 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 fears 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, vertigo, 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 Myocardial infarction anxiety disorder. Clarifying how the illness came Endocrine Diabetes mellitus IIypercalcemia about and in what order symptoms occurred can Hyperthyroidism' help. A medical illness that might have caused IIypocalcemia IIypothyroidism physical signs and symptoms before anxiety be Pheochromocytoma came a problem can lead the physician to suspect Gastrointestinal

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