Ms. W, a 73-year-old widow with no psychiatric history, visits her primary care physician because she is concerned about her memory. She denies impairment in other cognitive domains—such as executive function—or activities of daily living.
Ms. W relates prominent worries about her health and finances and those of her grandchildren. She describes daily restlessness, sleep-onset insomnia, difficulty concentrating, and mild episodic dysphoria. She says she’s always been a “worry wart” but her worry and other symptoms have become increasingly intrusive over the past 5 years with a series of deaths in her family. Ms. W’s medical history includes hypertension and type 2 diabetes. Unsure how to treat her, the physician refers Ms. W to a psychiatrist.
Older adults with anxiety symptoms often are dissatisfied with treatment because they believe they receive insufficient help. This complaint is probably valid because limited data support pharmacologic interventions for anxiety in older adults, and therapy is often based on inferences from studies in younger subjects. Moreover, many anxious older patients are treated with benzodiazepines, which increases their risk for cognitive impairment and injuries.1,2
Fortunately, growing evidence points to 2 treatment modalities for anxiety disorders in patients age ≥65:
- pharmacotherapy with antidepressants, benzodiazepines, and (perhaps) buspirone
- cognitive-behavioral therapy (CBT) for generalized anxiety disorder (GAD), panic disorder (PD), and mixed anxiety syndromes.
A common, debilitating problem
Anxious older adults report diminished perceived health, physical activities, and quality of life and increased loneliness compared with their nonanxious counterparts.1 The prevalence of anxiety disorders in older patients ranges from 0.4% for obsessive-compulsive disorder to 11.5% for GAD.3
Older adults with GAD present with a constellation of medical, psychiatric, psychological, and psychosocial features (Table 1).1,3-12 Anxiety disorders in older adults also may co-occur with major depressive disorder, other psychiatric conditions, or dementia, which can complicate diagnosis and treatment.
Table 1
Is it GAD? Common features in older adults
| Demographics |
| More prevalent at age |
| More common in women |
| Medical |
| Frequent visits to primary care |
| Low satisfaction with medical care |
| ≥2 chronic physical illnesses |
| ≥1 adaptive behavior limitations |
| Cognitive impairment, particularly verbal memory |
| Psychiatric |
| History of GAD symptoms (5 to ≥20 years) |
| Physiologic anxiety symptoms: restlessness, fatigue, muscle tension |
| Depressive symptoms |
| Prescribed a benzodiazepine |
| Presence of anxiety disorders |
| Suicidal ideation, particularly if depressed |
| Psychological |
| External locus of control |
| Neuroticism |
| Psychosocial |
| Limited social network |
| Perceived low instrumental support |
| Recent losses and traumatic life events |
| Loss of partner |
| GAD: generalized anxiety disorder |
| Source: References 1,3-12 |
CASE CONTINUED: Anxious, not depressed
You screen Ms. W with the Geriatric Depression Scale (short form; GDS) and Beck Anxiety Inventory (BAI). Her scores indicate no depression and moderate anxiousness. A neuropsychological screen finds no cognitive impairments. Based on the clinical interview and screening, Ms. W meets DSM-IV-TR criteria for GAD.
Psychopharmacologic interventions are first-line treatment for older adults with anxiety disorders, but you might consider other strategies because:
- Older patients may have increased vulnerability to medication side effects.
- Few randomized, placebo-controlled trials have examined psychopharmacologic interventions specifically for anxious older adults.
First-line pharmacotherapies
When selecting pharmacotherapy for an older adult with anxiety, take into account:
- physiologic changes in drug metabolism (older patients metabolize drugs more slowly than younger patients)
- comorbid medical problems
- polypharmacy (many older patients are taking multiple medications for multiple conditions, which increases the risk of drug-drug interactions).
Pharmacologic management of anxiety typically has included benzodiazepines, tricyclic antidepressants, barbiturates, and antihistamines. Newer antidepressants have emerged as first-line treatment for several anxiety disorders and mixed anxiety-depression syndromes, however, because of their more tolerable side-effect profiles, especially when used long-term.14 These antidepressants include:
- selective serotonin reuptake inhibitors (SSRIs)
- serotonin/norepinephrine reuptake inhibitors (SNRIs).
Citalopram—started at 10 mg/d and titrated to 30 mg/d as tolerated—was used in the only prospective, double-blind, randomized, controlled trial of an SSRI in older patients with anxiety disorders. In this 8-week trial, Clinical Global Impression scale scores and Hamilton Anxiety scale scores improved.15 In other investigations: