How anxiety presents differently in older adults
Age-related changes, medical comorbidities alter presentation and treatment
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Although anxiety disorders are common at all ages, there is a misconception that their prevalence drastically declines with age. For this reason anxiety disorders often are underdiagnosed and undertreated in geriatric patients, especially when the clinical presentation of these disorders in older patients differs from that seen in younger adults.
In older persons, anxiety symptoms often overlap with medical conditions such as hyperthyroidism and geriatric patients tend to express anxiety symptoms as medical or somatic problems such as pain rather than as psychological distress. 1 As a result, older adults often seek treatment for depressive or anxiety symptoms from their primary care physician instead of a psychiatrist. Unfortunately, primary care physicians often miss psychiatric illness, including anxiety disorders, in geriatric patients.
Anxiety may be a symptom of an underlying psychiatric disturbance, secondary to a general medical condition, or induced by dietary substances, substances of abuse, or medications. Late-life anxiety often is comorbid with major depressive disorder (MDD) ( Box ) and other psychological stressors as older adults recognize declining cognitive and physical functioning. 2 Anxiety disorders commonly begin in early adulthood, tend to be chronic and interspersed with remissions and relapses, and usually continue into old age. 3 In generalized anxiety disorder (GAD), there is a bimodal distribution of onset; approximately two-thirds of patients experience onset between the late teens and late 20s and one-third develop the disorder for the first time after age 50. 3
Prevalence rates for anxiety disorders among older adults (age ≥55) range from 3. 5% to 10. 2%. 4 These rates are slightly lower than those for younger adults. 5 Among older adults, presence of a 12-month anxiety disorder was associated with female sex, lower education, being unmarried, and having ≥3 or more chronic conditions. 6
Comorbid anxiety and depression: Highly prevalent, poorer outcomes
The Longitudinal Aging Study Amsterdam study—one of the largest epidemiologic studies to examine comorbidity of anxiety disorders and depression in patients age 55 to 85—found that 48% of older persons with primary major depressive disorder (MDD) also had a comorbid anxiety disorder, whereas approximately one-fourth of those with anxiety disorders also had MDD.a Pre-existing anxiety disorders, such as social phobia, obsessive-compulsive disorder, specific phobia, agoraphobia, and panic disorder, increase the risk of developing depression.b Rates of comorbid anxiety and depression increase with age.c
Late-life MDD comorbid with generalized anxiety disorder or panic disorder is associated with greater memory decline than MDD alone.d In addition, comorbid anxiety and depression is associated with greater symptom severity and persistence, greater functional impairment, substance dependence, poorer compliance and response to treatment, worse overall prognosis and outcome than patients with either disorder alone,e and greater likelihood of suicidal ideation in older men.f
a. Beekman AT, de Beurs E, van Balkom AJ, et al. Anxiety and depression in later life: co-occurrence and communality of risk factors. Am J Psychiatry. 2000; 157(1): 89-95.
b. Goodwin RD. Anxiety disorders and the onset of depression among adults in the community. Psychol Med. 2002; 32: 1121-1124.
c. Merikangas KR, Zhang H, Avenevoli S, et al. Longitudinal trajectories of depression and anxiety in a prospective community study: the Zurich Cohort Study. Arch Gen Psychiatry. 2003; 60: 993-1000.
d. DeLuca AK, Lenze EJ, Mulsant BH, et al. Comorbid anxiety disorder in late life depression: association with memory decline over four years. Int J Geriatr Psychiatry. 2005; 20(9): 848-854.
e. Merikangas KR, Kalaydjian A. Magnitude and impact of comorbidity of mental disorders from epidemiologic surveys. Curr Opin Psychiatry. 2007; 20: 353-358.
f. Lenze E, Mulsant BH, Shear MK, et al. Comorbid anxiety disorders in depressed elderly patients. Am J Psychiatry. 2000; 157: 722-728.
Anxiety and disability risk
Anxiety disorders affect geriatric patients more profoundly than their younger counterparts. Persons age ≥65 who have an anxiety disorder are 3 to 10 times more likely to be hospitalized than younger individuals. 1 Anxiety is associated with high rates of medically unexplained symptoms, increased use of health care resources, chronic medical illness, low levels of physical health-related quality of life, and physical disability. 7,8
Anxiety symptoms may predict progressing physical disability among older women and reduced ability to perform activities of daily living over 1 year. 9 Anxious geriatric patients are less independent and increase the burden on family and caregivers. 10 Anxiety disorders are associated with lower compliance with medical treatment, which could worsen chronic medical conditions and increase the risk for nursing home admission. 11 Anxious older adults report decreased life satisfaction, memory impairment, poorer self perception of health, and increased loneliness. 12
Generalized anxiety disorder
Although GAD is the most common anxiety disorder among geriatric patients, with a prevalence of 0. 7% to 9%, 13 it remains underdiagnosed and undertreated. 14 In a cross-sectional observational study of 439 adults age ≥55 with lifetime GAD, approximately one-half experienced onset after age 50. 15 Late onset is associated with more frequent hypertension and a poorer health-related quality of life than early onset. 15
Compared with younger individuals, older persons with GAD have a greater variety of worry topics, including memory loss, medical illnesses, and fear of falls, 16 but worry less about the future and work than younger patients. This type of anxiety is largely situational and temporary, and often accompanies comorbid medical problems (Table 1) .
A study comparing older (age ≥60) and younger obsessive-compulsive disorder (OCD) patients found that the clinical presentation of the disorder does not substantially differ between age groups; however, geriatric patients had fewer concerns about symmetry, needing to know, and counting rituals. Handwashing and fear of having sinned were more common. 17
OCD is fairly uncommon in geriatric patients. Prevalence rates decrease with age, ranging between 0% and 0. 8% among persons age ≥60. 18 OCD seldom begins in late life; most geriatric patients with OCD have had symptoms for decades. By late life, most individuals with OCD improve, although they may continue to experience clinical or subclinical symptoms. 19 However, 1 report found a second peak of incidence of OCD in women age ≥65. 20 Case reports of late-onset OCD have found evidence of cerebral lesions, often in the basal ganglia, which suggests a possible neurodegenerative pathophysiology. 21
DSM-IV-TR criteria for generalized anxiety disorder
Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance)
The person finds it difficult to control the worry
The anxiety and worry are associated with 3 or more of the following symptoms with at least some symptoms present for more days than not for the past 6 months:
The focus of the anxiety and worry is not confined to features of an axis I disorder
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
The disturbance is not due to the direct physiological effects of a substance or a general medical condition and does not occur exclusively during a mood disorder, a psychotic disorder, or a pervasive developmental disorder
Source: Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000
Posttraumatic stress disorder
Untreated posttraumatic stress disorder (PTSD) often is assumed to be a chronic disorder. Recollections of past trauma may lead to new PTSD symptoms in older patients. Neurodegeneration of memory pathways and cognitive impairment associated with Alzheimer‘s disease or vascular or alcohol-related dementia may disinhibit PTSD symptoms in patients whose PTSD was fairly well controlled. 22
Life events associated with aging—death of a spouse, financial and physical decline, chronic pain, or diminished cognitive coping resources—may precipitate or revive PTSD symptoms associated with earlier exposure to severe psychological trauma. 23 These life changes also may precipitate socalled delayed PTSD, when symptoms relating to past traumatic experiences present for the first time. Geriatric patients may be more likely than younger persons to deny their PTSD symptoms if their cultural background emphasizes stoicism and fortitude. 24
Specific phobias. The prevalence of specific phobias drops dramatically in late life, although older patients might underreport symptoms. Many older persons are afraid of falling. Approximately 60% of older adults with a history of falling—and 30% of older individuals with no such history— report this fear. Fear of falling is more prevalent in women and increases with age. 25,26 This fear may be a protective response to a real threat that prevents older persons from attempting high-risk activities, but it also can cause patients to restrict their activities, which can result in decreased social, physical, or cognitive functioning and loss of in-dependence. 25
Social phobias (social anxiety disorder).
Among older adults, common social phobias include eating food around strangers, and—especially in men—being unable to urinate in public bathrooms. In a cross-sectional observational study, social anxiety disorder (SAD) was more common among older persons who reported stressful life events, such as death of a spouse. 27 MDD, specific phobia, and personality disorder are associated with SAD in geriatric patients. 27 Prevalence rates of SAD appear to slightly decrease with age, although the condition remains common in geriatric patients—5% of older adults report lifetime prevalence—and its presentation is similar to that seen in younger adults. 27
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 (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 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: