Anxiety in the Older Adult Population: Key Considerations for Treatment

Anxiety disorders are the most prevalent psychiatric disorders and can affect people at every stage of life. Although not every older person with symptoms of anxiety has a diagnosable illness, it has been estimated that nearly 14% of the older adult population meets diagnostic criteria for an anxiety disorder. The most common anxiety disorders diagnosed in older adults are generalized anxiety disorder (GAD) and specific phobias. Anxiety disorders affect a remarkable number of older adults but are often underrecognized and underdiagnosed.¹

Risk Factors for Anxiety in Older Adults

Certain risk factors can increase the likelihood that an older adult may develop an anxiety disorder, including:¹

• Alcohol or prescription medication misuse or abuse
• Chronic medical conditions
• Difficult events in childhood
• Excessive worry or preoccupation with physical health symptoms
• Overall feelings of poor health
• Physical limitations in daily activities
• Sleep disturbance
• Side effects of medications

What Does Anxiety Look Like in Older Adults?

Compared to younger adults, older patients tend to demonstrate physical symptoms such as digestive issues or tachycardia and may be susceptible to fatigue, experience muscle tension, and sleep disturbances.³ Signs and symptoms of anxiety disorders in the elderly include:²

• Excessive or irrational worry/fear
• Lack of routine or consumed by routine
• Avoidant behavior, especially of social environments
• Excessive concern for safety
• Tachycardia, dyspnea, trembling, nausea, diaphoresis
• Sleep disturbances (insomnia, oversleeping, nightmares)
• Muscle tension, pain, or weakness
• Hoarding
• Depression
• Alcohol or other CNS depressant misuse

It is estimated that between 25-80% of older adults with a diagnosed anxiety disorder also have depression.⁵  Depression in the older adult population may also present differently when compared with a younger individual. Patients with comorbid depression and anxiety are at a heightened risk for suicidality and functional impairment.

It is likely that many older adults have experienced symptoms of anxiety earlier in life and now identify these feelings as normal and do not seek help. Furthermore, symptoms of anxiety may be inadvertently attributed to other comorbidities or deemed as adverse effects of medication.²

How Does Anxiety Impact Older Adults?

Anxiety can worsen an older adult’s physical health, inhibit the ability to perform daily activities, and reduce feelings of well-being. It can further lead to cognitive impairment and a poor quality of life.^{2, 6} It is important to recognize that anxiety disorders in the elderly are commonly associated with co-morbid psychiatric and medical conditions. For example, anxiety has been associated with an increased risk of cardiovascular and cerebrovascular morbidity and mortality. Specifically, a large meta-analysis found that patients with anxiety were associated with a 26% increased risk for cardiac disease and 48% increased risk for cardiac death. ⁶

Anxiety disorders in older adults can impact both treatment and outcomes in disease state management. For example, 13-46% of older adults with COPD also have a diagnosed anxiety disorder. This comorbidity has been linked to a decreased ability to complete daily activities as well as an increased risk of both hospitalization and suicidal ideation. As another example, the combination of depressive and anxiety symptoms in patients with type 2 diabetes has been found to translate to worse glycemic control. Additionally, anxiety symptoms have been associated with increased rates of decline in patients with cognitive diseases such as Alzheimer’s or Parkinson’s disease.⁷

Lastly, anxiety disorders in the elderly population are associated with higher total healthcare costs. These patients frequently utilize emergency department services, have an increased number of inpatient hospital stays, and see their primary care physicians more often. Patients with anxiety disorders are also at risk for polypharmacy, which can further increase healthcare-associated costs.^{2, 4}

How is Anxiety Treated in the Older Adult Population?

The goal of treatment should be to improve the patient’s overall functioning by targeting the symptoms that are most disabling or distressing. In order to best achieve a response or remission, treatment should be individualized and patient specific.³

In general, non-pharmacologic treatments are prioritized over pharmacological approaches in the treatment of geriatric anxiety. Non-pharmacologic management may include lifestyle modifications, supportive and/or dynamic psychotherapy, cognitive behavioral therapy, relaxation training, meditation exercises, and more. In regards to GAD, initial treatment can consist of medication, psychotherapy, or a combination of both.^2,8

As discussed in our article Pharmacologic Treatment Options for Generalized Anxiety Disorder, the selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) are generally considered first-line options for the treatment of GAD based on their safety and tolerability. When selecting an antidepressant for an older adult, it is necessary to consider specific patient characteristics.

Pharmacotherapy choice should include an assessment of:⁹

• Past medication trials and response
• Comorbid medical conditions
• Comorbid psychiatric conditions
• Concomitant medications and drug interactions
• Medication tolerability and safety

Antidepressants should usually be started at lower doses in elderly patients. Although they may also experience common side effects of antidepressants, such as headache, gastrointestinal distress, dizziness, insomnia, or sedation, older adults may also be more sensitive to adverse effects such as anticholinergic side effects, falls, hyponatremia, and, rarely, gastrointestinal bleeding.^9,12

Other antidepressants, benzodiazepines, hydroxyzine, buspirone, pregabalin, and second-generation antipsychotics may be considered as treatment options for GAD; however, they all have additional precautions and require close monitoring in elderly patients.¹⁰ Discussed at length in our article Beers Criteria Updates with a Focus on Psychiatric Medications, most of the treatments for GAD are listed as potentially inappropriate medications in the AGS Beers Criteria® and should be used with caution.¹¹

In addition to other patient-specific factors noted previously, clinicians should also be aware of pharmacokinetic and pharmacodynamic changes that occur with advancing age when assessing medication options for an elderly patient.

How Age-related Changes Impact Anxiety Medications

Elderly patients may be more sensitive to any given drug dose or concentration, and starting doses of antidepressants in the elderly are often lower than those typically utilized in younger patients. Furthermore, drug half-life may be increased in the elderly, and time to steady state, as well as time to resolution of dose-dependent adverse effects, can be longer.¹²

It is generally accepted that time to antidepressant response may be longer in the elderly, with potentially 2-3 months’ time needed to establish full benefit of a selected medication, though moderate improvements may start to be seen within 4-8 weeks.¹²

In Conclusion

With the number of Americans 65 and older expected to double from 48 million to 96 million in 2060, the prevalence of anxiety disorders in older adults will continue to grow.² The identification and management of anxiety disorders in older adults presents unique challenges to practitioners, though appropriate diagnosis and treatment is key to reducing significant disease-related consequences.

Predicting an individual’s likelihood of tolerating and responding to a psychotropic medication has proved challenging and has opened the door for pharmacogenetic guidance. PGx testing can assist clinicians in the selection of safe and appropriate treatments and is intended to be used adjunctively to a complete patient assessment. Important advancements have been made in the application of PGx testing in psychiatry in recent years and the PGx knowledge base in elderly populations is emerging.

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References

1. Mental Health America. Anxiety In Older Adults Fact Sheet. 2015.
2. Geriatric Mental Health Foundation. Anxiety and Older Adults: Overcoming Worry and Fear.
3. Subramanyam AA, Kedare J, Singh OP, Pinto C. Clinical practice guidelines for Geriatric Anxiety Disorders. Indian J Psychiatry. 2018;60(Suppl 3):S371-S382. doi:10.4103/0019-5545.224476
4. Vasiliadis HM, Dionne PA, Préville M, Gentil L, Berbiche D, Latimer E. The excess healthcare costs associated with depression and anxiety in elderly living in the community. Am J Geriatr Psychiatry. 2013;21(6):536-548. doi:10.1016/j.jagp.2012.12.01
5. Fiske A, Wetherell JL, Gatz M. Depression in older adults. Annu Rev Clin Psychol. 2009;5:363-389. doi:10.1146/annurev.clinpsy.032408.153621
6. Tully, P.J., Harrison, N.J., Cheung, P. et al. Anxiety and Cardiovascular Disease Risk: a Review. Curr Cardiol Rep 18, 120 (2016). 
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8. Corsonello A, Pedone C, Incalzi RA. Age-related pharmacokinetic and pharmacodynamic changes and related risk of adverse drug reactions. Curr Med Chem. 2010;17(6):571-584. doi:10.2174/092986710790416326
9. Frank C. Pharmacologic treatment of depression in the elderly. Can Fam Physician 2014;60(2):121-126.
10. Abejuela HR, Osser DN. The Psychopharmacology Algorithm Project at the Harvard South Shore Program: An Algorithm for Generalized Anxiety Disorder. Harv Rev Psychiatry. 2016 Jul-Aug;24(4):243-56.
11. By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019;67(4):674-694.
12. Avasthi A and Grover S. Clinical practice guidelines for management of depression in elderly. Indian J Psychiatry 2018;60(Suppl 3):S341-S362