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ANXIETY

Anxiety is a normal part of life, and it occurs over the entire life span. In particular, the experience of anxiety continues into later life. Just as younger people worry about things important to their stage of life, such as school, job, finances, and family, so too do older adults worry about health, family, finances, and their mortality. Elderly persons are as likely to react with fear or panic when danger is imminent as are their younger counterparts. Anxiety is a normal response to certain situations, and it can be useful in helping people to cope with problems and to manage threatening situations. Anxiety alerts us to threats and provides the physiological readiness needed for action. It may be very intense in certain situations yet still be considered normal. However, if it occurs when there is no threat, or if its intensity is far higher than the situation warrants, it is likely to be a symptom of an anxiety disorder. Excess anxiety that occurs repeatedly and leads to distress and disablement is usually caused by an anxiety disorder.

Elders are susceptible to many of the same treatable anxiety disorders that are seen in younger people. Sometimes this is because the disorder has been a lifelong condition. In other cases, its onset is in late life, and then risk factors are somewhat different than in younger people (see Figure 1). However, anxiety disorders seem to be more difficult to diagnose in the elderly population, and the treatments that have proven efficacy in younger populations are largely untested in elderly persons. The following three case examples exemplify the presentation of common anxiety disorders in older adults, and also illustrate the difficulties of diagnosing and treating these disorders.

Case one: generalized anxiety disorder

Ethel, age seventy-one, has always been a nervous woman. When interviewed by a psychiatrist, she describes feeling worried about future events that might happen. She explains she has had these worries "for as long as I can remember." At times, she has bouts with fatigue, headaches, and muscle aches. She says that what bothers her most is her chronic insomnia, and she has taken many different medications for sleep throughout her life. "I take my sleeping pills and I do just fine," she says. However, her family doesn't agree. Her daughter is distressed by Ethel's constant need for reassurance: "When mom's really worried about something, she'll phone me ten to twenty times in a day. Sometimes she seems paralyzed by her worries." When asked about this, Ethel reveals that she does have difficulty controlling her worries and that she takes an extra sleeping pill in the daytime for "nerves."

Ethel has classic signs of generalized anxiety disorder, a condition marked by constant distressing worries that the person finds difficult to control. Up to 2 percent of elderly people are afflicted by this condition at any time, which tends to be chronic (either constant throughout life, as in Ethel's case, or waxing and waning). Few people with this condition ever seek treatment for it. It is typical for older adults with generalized anxiety disorder to have many physical symptoms, such as Ethel's fatigue and headaches, so they often seek care from primary-care and specialty doctors for these physical symptoms, receiving unnecessary medical workups and medications without ever realizing the psychological basis for their problems.

When underlying anxiety is recognized by a doctor, it is often treated with a medication in the class called benzodiazepines. Valium (diazepam) is a well-known example of this type of medication. Unfortunately, this is not necessarily the best treatment, as benzodiazepines have side effects such as memory impairment, slowed reaction time (for example, when driving), and impaired balance, compounding problems an elderly person might have already. If so, these side effects are potentially of serious concern. Other treatments known to be efficacious for generalized anxiety disorder in younger adults, such as certain types of antidepressant medications and psychotherapies such as cognitive-behavior therapy may be better choices. However, these treatments have not yet been proven efficacious in the elderly population, though there are many reports of them alleviating this condition. In Ethel's case, her primary-care physician eventually convinced her of the underlying anxiety basis behind her symptoms and the need for a different type of medication. She was willing to try this because she trusted him, and within weeks both she and her daughter were feeling much better. She understood that this treatment would probably be needed long-term.

Case two: agoraphobia

Jim, age sixty-seven, never had any "nerve problems" in his life, according to his family. However, after suffering from a stroke, in which he lost movement on the left side of his body and fell, hurting his face and arm, he developed debilitating fears. After hospitalization, Jim received physical rehabilitation to help him regain his functioning. Nevertheless, he remains a "prisoner in his own home," as his son describes it: "Dad was fiercely independent before the stroke and did everything himself; now, he seems afraid to do anything alone." Jim says that because of his stroke-related weakness he can longer do many of the things outside the house that he used to do; he feels his walking is too unsteady. Jim's physical therapist is surprised at the degree of restriction. The therapist says that Jim does have enough strength; he simply becomes very fearful walking when someone is not nearby. When pressed, Jim agrees he has a great fear of falling: "Of course I'm scared; I could fall at any time and break my hip." Oddly, he is not reassured either by his physical therapist telling him that he is very unlikely to fall, nor by descriptions of other stroke sufferers who regained their independence. Jim cannot shake the anxiety that overcomes him when he thinks of going for a walk. As a result, Jim is considering moving from his home to a personal care home.

Jim's case is one of agoraphobia, literally "fear of the marketplace." This condition is characterized by fear of being trapped and unable to escape, or being alone and unable to get help in the event of having a physical problem. Agoraphobia is a common disorder in older individuals; it is estimated that it affects up to 8 percent of elderly persons. In younger individuals, agoraphobia usually develops after someone has experienced one or more panic attacks. In the elderly, however, agoraphobia often occurs for other reasons. Older adults can develop agoraphobia after medical events such as stroke, or traumatic events such as falls. The disorder can be difficult to detect, partly because the very nature of the disorder is to avoid going places, and this inhibits the person from seeking treatment. Jim's case exemplifies another diagnostic difficulty in the elderly: they often tend to normalize anxious behavior by either denying it exists or attributing it to realistic medical-related concerns.

Unfortunately, Jim's case illustrates a very common problem—that of anxiety disorders compounding or amplifying a disability caused by medical events. In Jim's case, a stroke that might only lead to minor changes in function is instead a severely disabling event when combined with agoraphobia. Another issue in this case is the need to rule out a depressive disorder. Depression is very common in elderly persons who have suffered medical events such as stroke, and it is frequently seen in those who suffer from an anxiety disorder. In Jim's case, his amplified disability might be not only from agoraphobia, but from depression as well. The optimal treatment of agoraphobia in younger adults is exposure therapy, by which the individual is repeatedly exposed to the feared situation while receiving professional advice from a therapist. As with other treatments for anxiety disorders, the efficacy of exposure therapy in older adults is unproven but promising. Some medications also help relieve agoraphobic symptoms, but these are also unproven in elderly persons.

Case three: obsessive-compulsive disorder

Susan, who is seventy, agrees that she is a very "clean" person. She spends much of each day cleaning and ordering her house. She describes having this behavior ever since childhood, when she avoided getting muddy and dirty. She says that her husband doesn't mind: "He says I'm a good housekeeper." Susan seems happy, too; proud of her clean house. However, more probing with questions reveals the extent of her problem: she explains that, all her life, she has felt very anxious about dirt, germs, and disorder. Earlier in her life she spent essentially all of each day cleaning, sometimes confining herself to one small square of a room, "so I could really get it clean." This behavior led to the loss of her only job (ironically, as a cleaning woman) and, for a time, estrangement from her husband and children. Her anxiety disorder was complicated by depression in her thirties and forties.

For the last several years, Susan has been taking a medication similar to Prozac (fluoxetine). She is doing much better: "Now I only spend three hours per day cleaning, and I can eat in a restaurant without bringing my disinfectant." But she still acknowledges significant distress at times, and while her relationship with her family is improved, there is still significant strain when her children bring their children over. "I just have to clench my teeth and bear it when they spill something."

Obsessive-compulsive disorder (OCD) is a combination of obsessions—repetitive, intrusive, unwanted thoughts, images, or impulses—and compulsions—repetitive acts done to ward off obsessions and/or to reduce anxiety. OCD occurs in about 1 percent of the elderly population and, since it is chronic, it will probably increase as individuals with this disorder enter the ranks of the aged. Susan's case exemplifies the chronic nature of OCD: she has suffered with it for sixty-plus years! Her case also illustrates an unfortunate complication of anxiety disorders: depression. The disability, in terms of job difficulties and strained relationships, is also typical of chronic anxiety disorders at any age. Susan's response to medications known as serotonin reuptake inhibitors is typical: helpful but incomplete. In younger adults, a type of psychotherapy known as behavior therapy can be effective; however its efficacy is unknown in elderly persons.

Other disorders

A panic attack is defined as a sudden intense feeling of fear associated with physical symptoms such as chest pain, shortness of breath, dizziness, shaking, feeling hot or cold, sweating, and nausea—in short, the symptoms caused by adrenaline release in a fight-or-flight response. A typical panic attack lasts about ten minutes. Panic disorder is diagnosed in people who have recurrent unexpected panic attacks along with persistent fear of these attacks or fear of what they mean or what they might cause. While this disorder is believed to be relatively rare in the elderly population, it may be that the disorder is difficult to diagnose because elderly individuals and their doctors attribute such physical symptoms to cardiac, respiratory, or other medical conditions. This misattribution has been illustrated earlier in this entry with other types of anxiety disorders as well.

Social phobia, also called social anxiety disorder, is a common disorder that typically begins early in life and usually lasts in some form throughout the life span; not surprisingly, it is seen in elderly persons, with about 1 percent suffering from the disorder. Its main feature is a fear of being criticized or humiliated while being observed or scrutinized by others. Its most common form is stage fright, or public-speaking phobia, but in the more severe cases, fear of eating, talking, or even being seen in public can paralyze individuals. Typically, elderly persons will have lived with this disorder for their entire lifetime and have adapted; that is, they have avoided feared situations (such as speaking in public) for so long that they view their lives as unaffected.

Specific phobias are the most common anxiety disorders: they are an intense, irrational fear of some situation. Common examples are acrophobia: fear of high places; and claustrophobia: fear of enclosed places. While considered less severe than other disorders, they can sometimes be quite disabling (e.g., the acrophobic who quits his job in a high-rise building). Similar to social phobia, elderly persons with specific phobias will probably have had these conditions for their entire life and have changed their lifestyle to avoid the feared situation or object.

Post-traumatic stress disorder (PTSD) is a type of response to an event that threatens or causes serious physical harm or even death, while also causing feelings of horror and/or helplessness. For example, being mugged or raped, or being shot at in battle can cause PTSD. It is diagnosed if the individual reexperiences the trauma in the form of nightmares, visions, or flashbacks, and if he or she exhibits chronic avoidance behavior and hyperarousability. The prevalence of this disorder is unknown in older adults. While it is common in such groups as combat veterans, it can also occur after serious medical events such as stroke and heart attack. In younger adults, PTSD tends to be chronic, lasting decades, and it is typically only partly responsive to medication (serotonin reuptake inhibitors). The course and response to treatment of this disorder in elderly persons is unknown, but as the combat veterans from the Korean and Vietnam wars grow older, much more will need to be known about this disorder as it presents in older adults.

Many older adults have problems with anxiety at some point in their life but do not have symptoms that meet the criteria for one (or more) of the above-described disorders. This is partly because the disorders described above were validated in younger age groups; thus, they may not describe the underlying disorder of many elderly persons suffering from symptomatic anxiety. As research in the field of geriatric psychiatry increases, anxiety disorders unique to older adults may be discovered. In any event, an older adult who suffers from anxiety should not be dismissed simply because their symptoms do not share features with the disorders described above.

The case examples presented here show some typical features of anxiety disorders as they present in older adults: they are common, though less so than younger adults, and they are not simply a "normal" reaction to aging or medical events. Further, they tend to be chronic and lead to much distress and disability, especially in combination with disabling chronic medical conditions such as stroke.

The problems with recognition and treatment of anxiety disorders in later life are twofold. First, there is the difficulty recognizing the disorder in an individual who may have lived with anxiety their entire life and view it as normal, or who may misattribute anxiety symptoms to medical problems common in this age group. Second, treatment options are for the most part unproven in older populations, due to the lack of controlled clinical trials for elderly persons with anxiety disorders. On the other hand, it is known that elderly people with depression respond to medication and psychotherapy just like their younger counterparts, and it is likely that this will be true for anxiety disorders as well. In the future, understanding of the presentation and treatment of anxiety disorders in the elderly will improve if there is better education of the public about these disorders and more treatment research to assure that potential treatments can find their place with elderly populations, just as in younger adults.

ERIC LENZE M. KATHERINE SHEAR

See also DEATH ANXIETY; DEPRESSION; GERIATRIC PSYCHIATRY.

BIBLIOGRAPHY

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, D.C.: APA, 1994.

BEEKMAN, A. T. F.; DE BEURS, E.; VAN BALKOM, A. J. L. M.; DEEG, D. J. H.; VAN DYCK, R.; and VAN TILBURG, W. "Anxiety and Depression in Later Life. Co-occurrence and Communality of Risk Factors." American Journal of Psychiatry 157 (2000): 89–95.

FLINT, A. J. "Epidemiology and Comorbidity of Anxiety Disorders in the Elderly." American Journal of Psychiatry 151 (1994): 640–649.

FLINT, A. J. "Management of Anxiety in Late Life." Journal of Geriatric Psychiatry 11 (1998): 194–200.

KRASUCKI, C.; HOWARD, R.; and MANN, A. "Anxiety and Its Treatment in the Elderly." International Psychogeriatrics 11 (1999): 25–45.

APHASIA

See LANGUAGE DISORDERS