Management of Anxiety in Late Life

Presentation of Anxiety

Primary anxiety disorders include generalized anxiety disorder, panic disorder, posttraumatic stress disorder, and obsessive-compulsive disorder (OCD); there is very little age-specific information on older adults with anxiety. This is in part due to a lack of age-specific studies, and in part reflects that criteria for some of these primary anxiety disorders have gradually evolved over the last 25 years. Also, some primary anxiety disorders frequently begin at an early age, and so patients often enter late life with the conditions. Others, like generalized anxiety disorder (GAD), one of the largest components of the primary anxiety disorders, occur in late life. GAD is relatively uncommon in young adults but the prevalence increases with age, particularly in mid to late life, where GAD is at least twice as common in women than in men. Some trials examining patients with GAD have revealed that at baseline, it is not unusual for the duration of the illness to be 10 years. The DSM diagnostic criteria for GAD have undergone three different revisions over the last 24 years. As a result, studies done during that period have used slightly different variations of the criteria, and it is difficult to generalize about the resulting studies that have been done. The speaker noted that the current criteria for a diagnosis of GAD have been considerably simplified. Dr. Burke discussed the case of “Mrs. G”, a 79-year-old woman who presented for her annual exam, to demonstrate a typical presentation of a patient with generalized anxiety disorder. She complained of difficulty falling asleep, feeling tense and tired all the time, and having sweaty palms. “Mrs. G” explained that she was “driving her husband and her children crazy,” and that, like her mother and grandmother, she has always been “high-strung.” She stated, however, that her physical health was otherwise perfect.

Pharmacologic Treatment Options and Assessment

Primary anxiety disorders often occur with other anxiety disorders (eg, depression). In fact, having a primary anxiety disorder places the patient at greater risk for developing depression in late life. In a study by Beekman,¹ it was found that 25-50% of older patients with any anxiety disorder suffered from comorbid depression, while nearly 50% of patients with major depression suffered from a comorbid anxiety disorder. Burke noted that several pharmacologic treatments are very efficacious for anxiety disorders but are not very effective for treating depression. As a result, physicians usually begin with treatments that will treat both affective disorders and primary anxiety disorders.

Patients who suffer from comorbid depression and anxiety are particularly difficult to treat and have the worst outcomes, including increased suicide risk, worse recovery rates, higher relapse and recurrence rates, and, consequently, often have recurring appointments with their physicians for extended periods of time. “I have a group of these patients who I have followed for years, and I am always struck by the fact that while I have been able to alleviate some of their symptoms, many of them never experience a full remission,” Dr. Burke said. Medical disorders and common physical illnesses can manifest themselves as symptoms of anxiety (eg, thyroid disease, chronic obstructive pulmonary disease [COPD], delirium [which often has a strong component of anxiety associated with it]). A variety of medications are associated with anxiety as a side effect. When treating patients with anxiety, physicians should review their medications to determine what is contributing to patients’ anxiety. Caffeine, alcohol, and benzodiazepine misuse are common culprits. “Benzodiazepine discontinuation is an underrecognized form of severe anxiety presentation, especially people who have taken something for a long time and then stop taking it,” he said. Treatment should focus on obtaining acute control of symptoms, remission of core symptoms, and alleviation of comorbid conditions, restoring function, improving quality of life, and preventing relapses and recurrences.

FDA-approved medications for the treatment of generalized anxiety disorder include benzodiazepines such as alprazolam and clonazepam, the 5-HT1A receptor agonist buspirone, the selective serotonin reuptake inhibitors (SSRIs) paroxetine and escitalopram, and the selective serotonin-norepinephrine inhibitor venlafaxine. In discussing treatment, Dr. Burke reiterated the lack of age-specific or long-term data, and that most generalizations are derived from studies of younger adults.

Benzodiazepines
Benzodiazepines have a more rapid onset of action than antidepressants; for instance, some symptoms such as restlessness, tremors, and jitteriness tend to improve relatively quickly. While benzodiazepines exhibit benefits during the beginning of treatment, antidepressants show greater benefit after 6-8 weeks of use. The side effect profile of the benzodiazepines is not favorable for older patients since it includes sedation, increased risk of falls and confusion, as well as physiologic dependence.

Selective Serotonin Reuptake Inhibitors
Selective serotonin reuptake inhibitors (SSRIs) are efficacious in treating depression and most anxiety disorders. An advantage of these drugs is that they are administered in once-daily doses and are generally well tolerated. The speaker pointed out that there is little evidence that any one SSRI is more efficacious than another for depression or anxiety; although differences in tolerability and potential for drug-drug interactions does separate the drugs. For example the SSRIs with the least effect on the cytochrome P-450 system, an important source of drug-drug intereactions, include escitalopram, citalopram, and sertraline. The most common side effect of the SSRIs is nausea. Some patients also experience insomnia and/or sedation, and sexual dysfunction and weight gain can occur. Less common but important side effects include hyponatremia apathy, anorexia, and extrapyramidal side effects. Recent epidemiologic studies have shown an increased incidence of upper GI bleeding in patients who are taking SSRIs, with an increased risk in patients taking nonsteroidal anti-inhibitors.

Tricyclic Antidepressants
Tricyclic antidepressants are effective, with nortriptyline being the best studied agent, but should be used with caution given their anticholinergic side effects and tendency to cause orthostatic hypotension with resultant risk for falls. In patients with co-existing anxiety and depression, the speaker warned against beginning treatment with buspirone or a benzodiazepine, “unless you are really sure that this is a primary anxiety disorder.” He recommended starting at the smallest dose possible, or even every-other-day dosing of a SSRI antidepressant (eg, sertraline 25 mg for 3-4 days or escitalopram 5 mg for 3-4 days). The dose can be increased if the patient tolerates the initial treatment. Starting at a low dose minimizes the risk of GI problems and the chance of a significant increase in anxiety. “This is a group of people that I would consider for early referral if they do not respond,” he said.

Improving Compliance
In order to enhance compliance, Dr. Burke recommended getting family members involved, warning patients ahead of time about potential side effects and when they will subside, and informing patients that symptoms may not improve with the first medication; in addition, they need to be told that there are other choices if the first medication is not effective or causes a side effect that necessitates a switch. He also urged patients to speak with their provider before they stop taking their medication for any reason.

Complexities of the Treatment of Anxiety

Susan K. Schultz, MD, Associate Professor, Department of Psychiatry, University of Iowa, Iowa City, discussed the reasons that anxiety is difficult to treat from both a psychiatric and a general practice standpoint, and described the interface of cognitive decline in anxiety in the older patient. “Our tendency is to frame things in specific diagnostic categories,” which makes cormorbid diagnoses problematic; for instance, if depression appears to be the primary problem, then generalized anxiety is usually not diagnosed.

From a clinical standpoint, Dr. Schultz highlighted a study by Jorm et al,² which demonstrated that, symptomatically, anxiety is probably much more commonly treated or commonly addressed than one would recognize if only epidemiologic studies were examined. The speaker stated the possibility that “when we’re looking at the older population, one of the things that is fueling this relatively high prevalence of anxiety as a symptom is the progression of cognitive changes that may occur in later life.” The self-awareness of a change in memory may also contribute to this. As a construct, mild cognitive impairment is typically defined as a person who is having some type of memory changes without the diagnosis of dementia, no dramatic decrease in activities of daily living, and is still performing within the normal range of general cognitive assessment.

There are concerns about mild cognitive impairment in that there is no treatment at this point. “The construct of mild cognitive impairment is very much in evolution, and we need to be careful about making any conclusions from simply that assessment,” the speaker said. A study by Lyketsos et al³ revealed that mild cognitive impairment may be presenting as much psychiatrically as it is cognitively. Another study by Forsell and coauthors⁴ revealed that as a syndrome, anxiety was the most common syndrome manifestation of mild cognitive impairment. Dr. Schultz defined metacognition as a person’s ability to sense changes in oneself, and a metacognitive process as one’s own subjective judgment or one’s ability to learn or to remember information. Studies have shown that most older adults have a good sense of their functioning; however, those who report poor memory—even when they are generally intact in terms of general cognitive function—tend to have higher affective ratings.

In addition, persons who complain about their memory or suffer from memory-related anxiety seem to have impaired coping skills. The speaker recommended assessment of cognitive function for persons who are having new difficulties with anxiety or coping in late life, as often age-associated changes in memory are contributing to the clinical picture. She noted that after age 60, there is generally a change in cognitive skills in the population as a whole, irrespective of pathologic disorders. Dr. Schultz considered whether we should provide support for the cognitive and coping changes that occur in late life, rather than adhering to the expectation that medications must be used for every isolated symptom related to aging. Certain higher level cognitive functions are particularly vulnerable to age-related changes, such as “set shifting” or fluid cognitive skills. These skills include learning or complex planning of new information, integration of new circumstances or new environments rather than longer-term fluid skills (also known as cystallized skills). In a person who is experiencing normal age-associated cognitive changes due to altered fluid skills, what can appear to be a serious decrement in function may simply be the consequence of a new circumstance and the person’s inability to acclimate to that new circumstance.

Case Presentation

An 80-year old woman who lived alone was having difficulty coping with new expectations after the loss of her spouse, was developing worry and increased irritability, and experienced poor sleep and a decline in function. According to her daughter, she was more indecisive and she obsessed over her finances. When she presented to her psychiatrist, she had been receiving alprazolam for some time. She suffered from longstanding obsessive-compulsive disorder (OCD), and those problems increased in new situations. The speaker noted that it is normal for these patients to develop ritualistic behaviors as a means of coping with change. The patient was administered fluvoxamine, an SSRI commonly used for OCD. At a follow-up visit, she was doing equally poorly, so fluvoxamine was increased; afterwards, the patient developed delirium and was eventually placed in a nursing home, where she was assessed by Dr. Schultz. The speaker explained that in this case, the patient was having difficulty with set shifting due to her new situation and perhaps some cognitive decline; in this case, aggressive treatment with medications for OCD were not helpful, and were in fact detrimental. Rather, the patient may have benefited most from social support to reduce her difficulties in coping with her recent losses and adapting to her new situation.

Cognitive Decline

Dr. Schultz expressed the possibility that cognitive impairment may cause the development of anxiety in older patients. In addition, increasing doses of SSRIs may not be advantageous, but rather potentially harmful due to adverse affects of SSRIs. A review on the risk of hyponatremia with SSRIs by Kirby and Ames⁵ revealed that, within a couple of weeks of initiating therapy, it is not unusual for patients who are predisposed to hyponatremia to develop clinically significant hyponatremia that typically resolves with the discontinuation of the SSRI. Therefore, any patients who are known to be at risk for hyponatremia, or who develop evidence of new confusion or altered mental status, should have an evaluation of electrolytes. Similarly, the use of benzodiazepines for late-life anxiety may result in adverse sequelae, as benzodiazepines have been associated with impairments in gait and balance as well as an increased risk for confusion.

Due to the potential problems associated with psychotropic medications, an initial trial of non-medication interventions is preferred for late-life anxiety in the context of cognitive decline. A study by Sinoff and Werner⁶ demonstrated that memory complaint may place one at higher risk for anxiety and depression, and induces a projection toward a dementia syndrome. In addition, the speaker argued that once patients begin having memory problems, their ability to self-assess their cognitive decline is impaired. Among persons who have higher Mini-Mental State Examination scores, those with anxiety suffer from more functional impairment relative to their cognitive state than those without anxiety, which suggests that not only does anxiety cause greater functional disability, but that it is most operative at the early end of the spectrum. “This supports the notion that early on, when people are still self-aware of their own decline, is the greatest risk period for the development of anxiety,” she said. Interventions during this delicate period have to be conducted with great caution, the speaker warned. Social sources of distress must be addressed prior to the administration of medication. It is important to focus on quality of life, not just on eliminating symptoms, and ask how the patients can go out into the community and enjoy life. In Dr. Schultz’s opinion, if patients are asked ahead of time, they would reveal that they “don’t want every symptom to be aggressively treated; they want to have the best function possible in view of whatever disabilities they may incur.”

Nonpharmacologic Treatment Options

“We often see anxious, apprehensive, uncomfortable, needy older adults who are having a tremendously compromised quality of life because of those anxiety symptoms,” said Marianne Smith, MS, ARNP, CS, John A. Hartford Scholar, University of Iowa College of Nursing, Iowa City. In terms of quality of life, the speaker stated that we should think about the treatment options that are available for each individual patient, and how we can help them to be as comfortable and as functional as possible. Identifying the cause of anxiety symptoms is an important first step in selecting an intervention. Anxiety symptoms in a person with cognitive impairment will be treated very differently than in a person who is cognitively intact.

Throughout her presentation, Ms. Smith described various nonpharmacologic approaches for the treatment of anxiety symptoms and disorders. In the United States, pharmacologic intervention is the mainstay of anxiety treatment in all age groups, though nonpharmacologic interventions are quite efficacious. The speaker noted that in geriatrics, nonpharmacologic interventions, such as cognitive, behavioral, cognitive-behavioral, psychodynamic, and supportive therapies, should be used first to avoid side effects and polypharmacy issues. These interventions have demonstrated effectiveness, and are recommended in treatment guidelines, but are not regularly used with older adults. Cognitive restructuring is structured therapy aimed at identifying, evaluating, controlling and modifying negative, distorted, and often unrealistic thoughts that provoke anxiety. Reversing and controlling negative and difficult thoughts helps patients adopt more healthy and realistic views of events, which in turn, reduces feelings of apprehension, worry, and anxiety. Behavioral therapy aims to confront fears and promote habituation via systematic desensitization.

Other protocols mix cognitive and behavioral methods, which are often provided in a structured format. “Working through a standardized protocol of cognitive-behavioral exercises, where you identify an anxiety-provoking experience and then you identify alternative explanations, may follow an almost workbook-formatted set of steps,” said Ms. Smith. Research provides support that the traditional cognitive-behavioral interventions that have been used in younger persons with anxiety disorders can also have positive effects when applied in the same manner in the treatment of older adults. There is also some emerging research demonstrating that enhanced cognitive-behavioral therapy may work even better, which the speaker finds particularly encouraging.⁷ Additional measures that may facilitate even better outcomes than the standard cognitive-behavioral therapy include a telephone call during the week to check on the patient’s status, and taking more time during sessions to reiterate what was covered during the last session.

The speaker also discussed positive outcomes of supportive group therapy, which focused on encouragement, listening, reassurance and redirection, and opportunities for patients to support and connect with each other. “I was very encouraged by this particular format because it [using supportive methods] is something that all of us have the capacity to do in day-to-day practice.” In addition to restructuring thoughts and confronting fears, other interventions focus primarily on managing anxiety symptoms. These strategies are also aimed at preventing or reducing uncomfortable anxious feelings, and include positive self-talk, guided self-dialogue, thought-stopping, positive imagery, controlled breathing, relaxation training, and social skills training. Psychodynamic therapy is another alternative for treating anxiety. This insight-oriented talk therapy examines conflicts that have arisen and problems that have emerged throughout the person’s lifetime in order to help patients identify and release themselves from their often unrecognized subconscious dilemmas. It may be useful in treating older adults with uncomfortable—but not disabling—anxiety who are motivated to consider their problems in this framework.

Although there are no systematic studies on insight-oriented psychotherapy, there are also no data indicating that it is ineffective.⁸ In supportive therapy (eg, the nondirective talking therapy), daily problems, habits, and challenges are reviewed and patients are given support and encouragement. Problem-solving techniques are discussed, reality testing is offered, and patients are redirected in order to facilitate adaptive functioning. Cognitive-behavioral methods, such as thought-stopping techniques to stop recurrent negative thoughts, may be combined with encouragement and redirection into positive thoughts or experiences. The goal is to distract the patient from anxious, worrisome, and/or negative thoughts. Ms. Smith noted that supportive therapy is regularly used in combination with cognitive-behavioral therapy. She reported that supportive therapy has not been directly tested for the treatment of anxiety disorders, but findings from clinical trials in which persons in the comparison group received supportive therapy and achieved positive outcomes suggests that it can be very helpful.

Convincing a patient to participate in cognitive-behavioral therapy, which typically involves referral to a mental health specialist, may be more difficult than supportive therapy. Supportive therapy techniques can easily be provided by a wide range of health providers when patients with anxiety disorders or symptoms present for care. Psychoeducational strategies provide education about symptoms and symptom management. This type of therapy is regularly a part of cognitive-behavioral therapy, and can involve individual and group educational sessions, printed materials, and online information. The speaker stated that there is limited evidence to support the efficacy of this strategy in older adults. However, education is intuitively appealing, especially with patients who present with somatic symptoms and attribute their problems to medical causes.

There are a variety of alternative therapies available for elderly patients (eg, aroma therapy, music therapy, massage, therapeutic touch, etc), though they have mainly been developed in the context of anxiety-producing medical conditions (eg, cancer). Although there is no empirical support for their use in anxiety disorders, Ms. Smith notes, “When we know that the person is really uncomfortable and their quality of life is badly compromised, from my philosophical perspective, these interventions provide practical, acceptable ways of intervening with people without going to medications.” System-level interventions are designed to alter the system of care in which mental health services are provided to patients. These interventions include a brief intensive inpatient hospitalization to minimize a patient’s time spent in the hospital, an outpatient technique in which comorbid conditions are identified and treated, group interventions that include anxiety management and cognitive-behavioral therapy techniques, and anxiety care managers. These managers are specially trained to provide supervised care in collaboration with the patient’s primary care provider and study investigators using an evidence-based protocol. The outcomes of system level interventions, which are consistent with recommendations in the Surgeon General’s report, are promising but are not targeted specifically to older adults. The speaker noted the importance of additional clinical trials to determine the efficacy of these interventions.

Ongoing attention to identification and treatment of anxiety disorders was underscored by Young et al⁹ who collected data from a nationally represented sample of persons aged 19-97 years. During a 1-year period, over 80% of individuals with probable anxiety disorders were seen by a primary care provider. Although visits were common, treatment was not. Of these patients, 31% received some counseling and 17% received appropriate counseling; 25% were administered some medication and 20% were administered appropriate medication, indicating that anxiety is both under-and untreated in primary care. The authors concluded that older adults, in particular, were less likely than middle-aged persons to receive appropriate treatment. In conclusion, Ms. Smith stated that the intervention should be based on the type of diagnosis, the individualized symptom picture, concomitant medical conditions and medications, and the presence and extent of cognitive impairment.

According to the speaker, the therapeutic alliance often makes the difference in whether the patient experiences relief. It is important to take the time to listen and show compassion for these individuals. Older patients with anxiety need help in understanding that they have to continue with the designated intervention in order to experience relief of symptoms. The location and availability of services to certain patients also should be explored to assure that mental health and illness needs are met. The speaker concluded by noting the need for more collaborative and cooperative models to be explored, more clinical trials to be conducted, and the additional use of alternative care managers and nurses in the care of older adults with anxiety to be tested.