Evidence-Based Reviews

How anxiety presents differently in older adults

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

References

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

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Clinical Point

Older patients may present with panic symptoms, such as shortness of breath, dizziness, or trembling, that overlap with medical conditions

Agoraphobia. In older persons the prevalence of agoraphobia is 0. 6%.²⁸ Most cases are of early onset but the condition can present de novo following a stroke or other medical event and can inhibit activities needed for successful rehabilitation. Agoraphobia can present within the context of panic attacks as is seen in younger adults but most geriatric patients with agoraphobia do not have concurrent panic disorder. This phobia is more common in women, widowed or divorced individuals, patients with chronic health conditions, and those with comorbid psychiatric disorders.²⁹

Panic disorder

Panic disorder (PD) rarely starts for the first time after age 60, and most late-onset panic attacks are associated with medical and psychiatric comorbidities. PD tends to be less severe in older individuals than in younger adults.³⁰ Recent stressful life events or losses can predict onset and maintenance of PD. Older patients may present with panic symptoms, such as shortness of breath, dizziness, or trembling, that overlap with age-related medical conditions. PD may be prevalent in older patients with chest pain and no evidence of coronary artery disease.³¹ Panic symptoms that are secondary to underlying medical conditions, such as chronic obstructive pulmonary disease exacerbation, usually wax and wane.³²

Treatment

Clinical Point

SSRIs and SNRIs may be useful for several anxiety disorders in older patients; TCAs may be cardiotoxic and can lead to serious side effects

Treatment for anxiety disorders in geriatric patients may involve a combination of psychotherapy, pharmacotherapy, and complementary and alternative therapies. Treatment may be complicated if patients have ≥1 anxiety disorder or suffer from comorbid depression, substance abuse, or medical problems. As is seen with younger adults, the course of anxiety disorders in older patients waxes and wanes, but most disorders are unlikely to remit completely.³³ Aging may influence the effects of psychotropic medications in older patients. Increased distribution and decreased metabolism and clearance of medications results in higher medication plasma levels and longer elimination half-lives. Medication compliance in older patients may be complicated by:

older patients’ sensitivity to anticho-linergic side effects
coexisting medical illnesses
polypharmacy, particularly in institutionalized settings
sensory and cognitive deficits.³⁴

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) generally are safe and produce fewer side effects compared with tricyclic antidepressants (TCAs), especially in geriatric patients. SSRIs and SNRIs may be useful for GAD, PD, OCD, and PTSD in older patients.³⁵ TCAs can effectively treat anxiety symptoms but may be cardiotoxic and their anticholinergic properties can lead to serious side effects. Benzodiazepines often are used for acute or short-term anxiety management, but chronic use in geriatric patients can cause cognitive impairment, falls, and other serious side effects. Buspirone may be beneficial for GAD but is not effective for PD.³⁶ The drug is well tolerated in older persons, but may take 2 to 4 weeks to be effective ( Table 2 ).³⁵

Clinical Point

In older patients with GAD, CBT is associated with improvements in worry severity, depressive symptoms, and overall mental health

Pharmacotherapy for anxiety disorders in geriatric patients often is used in conjunction with psychotherapy. Psychotherapeutic approaches include cognitive-behavioral therapy (CBT), exposure therapy, dialectical behavioral therapy, and interpersonal therapy. Increasing evidence supports the effectiveness of psychotherapy in treating anxiety disorders in younger adults as well as in older patients, often in combination with pharmacotherapy.³⁷ In older patients with GAD, CBT is associated with a greater improvement in worry severity, depressive symptoms, and overall mental health compared with usual care.³⁸

In addition to traditional pharmacotherapy, complementary and alternative therapies often are used for late-life anxiety. These therapies include biofeedback, progressive relaxation, acupuncture, yoga, massage therapy, art, music, or dance therapy, meditation, prayer, and spiritual counseling.

Table 2

Pharmacotherapy for anxiety disorders in older adults

Medication	Comments
Selective serotonin reuptake inhibitors	May be useful for GAD, panic disorder, OCD, and PTSD
Serotonin-norepinephrine reuptake inhibitors	May be useful for GAD, panic disorder, OCD, and PTSD
Tricyclic antidepressants	Potential for cardiotoxicity and overdose, anticholinergic properties
Benzodiazepines	Chronic use can lead to cognitive impairment, falls
Buspirone	Effective for GAD, but not panic disorder; may take 2 to 4 weeks to be effective
GAD: generalized anxiety disorder; OCD: obsessive-compulsive disorder; PTSD: posttraumatic stress disorder
Source: Reference 35

Related Resources

Wetherell JL, Lenze EJ, Stanley MA. Evidence-based treatment of geriatric anxiety disorders. Psychiatr Clin North Am. 2005; 28(4): 871-896, ix.
Lenze EJ, Wetherell JL. Anxiety disorders. In: Blazer DG, Steffens DC, eds. The American Psychiatric Publishing textbook of geriatric psychiatry. Arlington, VA: American Psychiatric Publishing, Inc; 2009: 333-345.