Anxiety Disorders in Older Anxiety Disorders in Older PeoplePeople

George T. Grossberg, MDGeorge T. Grossberg, MDSamuel W. Fordyce ProfessorSamuel W. Fordyce ProfessorDirector, Geriatric PsychiatryDirector, Geriatric Psychiatry

Saint Louis University School of MedicineSaint Louis University School of Medicine

DisclosureDisclosure

None for this presentation.None for this presentation.

How Common is Clinically How Common is Clinically Significant Anxiety in OlderSignificant Anxiety in Older

ReferenceReference InstrumentInstrument PrevalencePrevalence

Beekman Beekman et alet al. 1998. 1998 DIS/DSM-IIIDIS/DSM-III 10.2%10.2%

Regier Regier et alet al. 1988. 1988 DIS/DSM-IIIDIS/DSM-III 5.5%5.5%

Bland Bland et alet al. 1988. 1988 DIS/DSM-IIIDIS/DSM-III 3.5%3.5%

Weissman Weissman et alet al. 1985. 1985 DIS/DSM-IIIDIS/DSM-III 4.6%4.6%

Saunders Saunders et alet al. 1993. 1993 GMS-AGECATGMS-AGECAT 2.5%2.5%

Different Types of Anxiety DisorderDifferent Types of Anxiety Disorder

Generalized Anxiety Disorder (common)Generalized Anxiety Disorder (common) Phobic Disorders ( common)Phobic Disorders ( common)

-- AgoraphobiaAgoraphobia-- social phobiasocial phobia-- Specific phobiaSpecific phobia

Panic disorder (rare)Panic disorder (rare) Post-traumatic Stress Disorder (uncommon)Post-traumatic Stress Disorder (uncommon) Obsessive Compulsive Disorder (rare)Obsessive Compulsive Disorder (rare) Anxiety Disorder due to a General Medical Anxiety Disorder due to a General Medical

condition (common)condition (common)

Putative Causes of Anxiety in Older Putative Causes of Anxiety in Older PeoplePeople

Genetic vulnerabilityGenetic vulnerability Structural brain changesStructural brain changes Medical illnessMedical illness Personality traitsPersonality traits Adverse life eventsAdverse life events

Medical Conditions Commonly Medical Conditions Commonly Associated with AnxietyAssociated with Anxiety

Hyperthyroidism; diabetes mellitusHyperthyroidism; diabetes mellitus Ischemic heart diseaseIschemic heart disease Chronic obstructive pulmonary diseaseChronic obstructive pulmonary disease Gastrointestinal diseaseGastrointestinal disease Parkinson’s diseaseParkinson’s disease Alzheimer’s diseaseAlzheimer’s disease StrokeStroke

Relationship between Medical Relationship between Medical Disorders and AnxietyDisorders and Anxiety

Co-occurrence of two common disordersCo-occurrence of two common disorders Somatic symptoms of anxiety (e.g. dyspnea)Somatic symptoms of anxiety (e.g. dyspnea) Anxiety as a psychological reaction to major Anxiety as a psychological reaction to major

medical illness (e.g., MI)medical illness (e.g., MI) Direct effect of illness on the brain (e.g. CVA, Direct effect of illness on the brain (e.g. CVA,

AD)AD) Medical illness causing anxiety symptoms (e.g., Medical illness causing anxiety symptoms (e.g.,

hyperthyroidism)hyperthyroidism) Anxiety as a side effect of medication (e.g. beta Anxiety as a side effect of medication (e.g. beta

agonists; anti-parkinsonian drugs)agonists; anti-parkinsonian drugs)

Scales to Assess AnxietyScales to Assess AnxietyMore Work NeededMore Work Needed

Worry ScaleWorry Scale State-Trait Anxiety InventoryState-Trait Anxiety Inventory Penn State Worry QuestionnairePenn State Worry Questionnaire Beck Anxiety InventoryBeck Anxiety Inventory Fear QuestionnaireFear Questionnaire Padua InventoryPadua Inventory

Treatment of Anxiety Disorders in Treatment of Anxiety Disorders in Older PeopleOlder People

Identify & manage comorbid medical Identify & manage comorbid medical problemsproblems

Identify & manage cormorbid psychiatric Identify & manage cormorbid psychiatric problems (esp. depression, psychosis & problems (esp. depression, psychosis & dementia)dementia)

Non-pharmacologicalNon-pharmacological PharmacologicalPharmacological

Non-PharmacologicalNon-Pharmacological Psychoeducation:Psychoeducation:

-- Explanation of the nature of anxiety & its Explanation of the nature of anxiety & its symptomssymptoms

CBT:CBT:-- Relaxation trainingRelaxation training-- Self-talk & imagerySelf-talk & imagery-- Cognitive restructuringCognitive restructuring-- Social Skills trainingSocial Skills training-- Distraction techniquesDistraction techniques-- ExposureExposure

Relaxation TrainingRelaxation Training

Progressive muscular relaxationProgressive muscular relaxation Controlled breathingControlled breathing Visual imageryVisual imagery

ExposureExposure

(Flooding)(Flooding) Systematic desensitizationSystematic desensitization Response preventionResponse prevention

PharmacologicalPharmacological BenzodiazepinesBenzodiazepines

-- Toxicity (amnesia & confusion; ataxia & Toxicity (amnesia & confusion; ataxia & unsteadiness)unsteadiness)

BuspironeBuspirone-- Toxicology good; efficacy & speed of onset poorToxicology good; efficacy & speed of onset poor

AntidepressantsAntidepressants-- TCAsTCAs-- SSRIsSSRIs-- SNRISNRI

Other drugsOther drugs-- Beta Blockers (often not ideal for older patients)Beta Blockers (often not ideal for older patients)-- Cholinesterase inhibitorsCholinesterase inhibitors

Use of Newer AntidepressantsUse of Newer Antidepressants

Initial increase in anxiety and insomnia in some Initial increase in anxiety and insomnia in some patientspatients-- start with very low dose in older patients start with very low dose in older patients

(e.g., 10 mg citalopream or 37.5 mg (e.g., 10 mg citalopream or 37.5 mg venlafaxine)venlafaxine)-- add low-dose short-acting benzodiazepine add low-dose short-acting benzodiazepine

for first two weeks (e.g., oxazepam, for first two weeks (e.g., oxazepam, lorazepam)lorazepam)

ConclusionConclusion

Increased realization of overlap between Increased realization of overlap between depression & anxiety in older peopledepression & anxiety in older people

Convergence of treatment approaches to Convergence of treatment approaches to depression & anxiety in older peopledepression & anxiety in older people

Combination treatment with psychological Combination treatment with psychological interventions and antidepressant interventions and antidepressant medication usually works bestmedication usually works best