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Anxiety Disorders in Late Life
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Anxiety Disorders in Late Life Cheryl N. Carmin
Jan Mohlman
Amy Buckley
University of Illinois at Chicago, Illinois, USA
Syracuse University, Syracuse, New York, USA
University of Illinois at Chicago, Illinois, USA
1. Epidemiology of Anxiety Disorders in Older Adults 2. Assessment and Treatment of Anxiety Disorders 3. Conclusions Further Reading
GLOSSARY cognitive behavior therapy A collaborative form of psychotherapy that involves facilitating patients’ changing their belief system via a Socratic dialogue focusing on those distressing thoughts that exacerbate negative emotions and maladaptive behaviors. ego-syntonic/ego-dystonic obsessions Terms typically used in describing whether obsessions are congruent or incongruent with one’s beliefs; an ego-dystonic obsession may include the belief that washing one’s hands for 15 minutes will prevent cancer with the understanding that, despite the persistence of the thought, it is illogical. epidemiology A branch of medical science that deals with the incidence/prevalence, distribution, and prevention of a disease or condition as well as the identification of atrisk populations. Likert scale A means of assigning a numerical intensity rating that is anchored by descriptive terms to a construct (e.g., I would describe my worry as 1 = very mild, 2 = mild, 3 = average, 4 = excessive, 5 = very excessive).
Recent epidemiological studies have underscored the ubiquitous nature of anxiety disorders, with
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approximately 25% of adults being affected over the course of their lifetimes. Furthermore, the economic burden of these disorders has been estimated at $42.3 billion, comprising 31% of psychiatric treatment costs. Given the prevalence of anxiety disorders, it is not surprising that an increasing amount of attention has been given to investigating the prevalence and treatment of these conditions. What is surprising, however, is how little attention has been given to anxiety disorders in what is the fastest growing segment of the population, namely the elderly. This article summarizes how the existing research literature informs us with respect to the epidemiology of anxiety disorders in the elderly and then examines the treatment outcome literature with regard to the individual anxiety disorders.
1. EPIDEMIOLOGY OF ANXIETY DISORDERS IN OLDER ADULTS The United States is aging. The U.S. Census Bureau predicts that more than 72 million adults will be age 65 years or over by the year 2030. Recent epidemiological studies underscore that anxiety disorders are the most prominent of the psychiatric conditions, with lifetime estimates nearing 25%. Despite the widespread prevalence and extensive cost to society of anxiety disorders, there is currently little data on the rate and phenomenology of anxiety disorders in the elderly population.
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1.1. General Prevalence Data It is generally believed that anxiety disorders occur less frequently in the elderly population than in younger adults. However, there have been only a small number of epidemiological studies that have tested this contention directly. A recent epidemiological study in the United States that included persons over 65 years of age is the Epidemiological Catchment Area (ECA) study, which included more than 18,000 noninstitutionalized adults. The ECA study systematically examined the rate of anxiety disorders at five sites across the country. Fully 30% of the ECA subjects were age 65 years or over. It was ascertained that the 1-month prevalence rate of anxiety disorders in the elderly was approximately 5.5%, lower than the 7.3% estimate for all adults surveyed. Furthermore, elderly women were nearly twice as likely to have anxiety disorders as were elderly men. The percentage of elderly adults with anxiety disorders was higher than that with any other psychiatric illness, including cognitive impairment, underscoring the need for appropriate identification and treatment in this population. Furthermore, rates of anxiety disorders were much higher than the 2.5% prevalence rate of affective disorders in this population. Other reviews of smaller scale epidemiological studies found that rates of anxiety disorders ranged between 0.7 and 19.0%. Similar 6-month prevalence rates of 3.5% have been found in Europe.
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the prevalence of GAD are not included in the ECA data and that other studies that find higher prevalence rates of GAD may be due to differences in their respective methodologies, for example, the decision rules applied in rendering a diagnosis.
1.3. Reliability of Epidemiological Studies
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There are several potential explanations for the wide variability of estimates of anxiety disorder prevalence in the elderly. The existing epidemiological studies use different methodologies, and this often makes it difficult to compare prevalence rates across individual studies. Some of the studies include institutionalized elderly adults, whereas others survey communitydwelling residents only. In addition, measures of anxiety symptoms validated on younger adults might not be applicable to older adults given that the experience and expression of anxiety may change with age. Likewise, the instruments used to assess anxiety in older adults might not have norms or other psychometric data that are established for older adults, let alone for very old adults. Further research is needed to delineate factors that contribute to the difference in prevalence estimates and to clarify the nature of anxiety in the elderly. Until then, estimates of prevalence rates of anxiety disorders in the elderly should be considered preliminary.
1.2. Epidemiology of Individual Anxiety Disorders
1.4. Comorbidity
Rates for specific anxiety disorders also vary across studies and differ between elderly males and females. Data from the ECA study suggest that phobias are the most frequently experienced anxiety disorder in the elderly, affecting an estimated 4.8% of older adults. Panic disorder (PD) and obsessive–compulsive disorder (OCD) in the elderly population are expected to occur only infrequently. Rates for PD are estimated to not exceed 0.3%, and when panic does occur in elderly adults, it tends to be in women. Similarly, rates of OCD among the elderly are low, with prevalence estimates being 3.5% at a maximum and with elderly adults residing in institutional settings accounting for the upper end of these prevalence estimates. Data regarding the prevalence of generalized anxiety disorder (GAD) suggest that it has a much more variable occurrence in the elderly population, ranging between 0.7 and 7.1%. It is important to note that data on
It is well known in the literature that anxiety disorders often co-occur with other diagnoses, including depression and other anxiety disorders. However, it is important to examine whether this is true for elderly persons as well. Research is beginning to shed light on the co-occurrence of anxiety and other psychiatric disorders in older adults. As with younger adults, depression most frequently co-occurs with anxiety disorders among elderly patients. In addition, when depression is the primary diagnosis in elderly adults, anxiety frequently co-occurs. In general, the delineation between depression and anxiety is not clear, and research suggests that it might be even less clear for older adults. Unlike anxiety or depression, the incidence of cognitive impairment increases with age. Research examining the relationship between anxiety and dementia in older adults typically finds that these syndromes often coexist. Symptoms of anxiety often occur in the
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context of dementia as well as in nondemented older adults. In summary, although the frequency with which anxiety disorders are present in older adults is lower than that in younger adults, these data may be confounded by methodological problems such as differences in diagnostic classification, commonalities between anxiety and depression in this population, and the frequent occurrence of anxiety symptoms accompanying medical conditions.
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2. ASSESSMENT AND TREATMENT OF ANXIETY DISORDERS
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2.1. Generalized Anxiety Disorder
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2.1.1. Assessment Diagnostic criteria for GAD have undergone considerable revision over the past 20 years or so. The most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) emphasizes chronic uncontrollable worry that causes significant distress or impairment as the hallmark symptom of the disorder. In adults of all ages, GAD is most often comorbid with other affective and anxiety disorders and is sometimes viewed as a vulnerability factor for the development of additional psychiatric problems. GAD is often secondary to depressive disorders in older adults. As noted by Carmin and colleagues in 1999, the only clinician-rated diagnostic interviews that have been found to yield reliable diagnoses with elderly patients are the Structured Clinical Interview Diagnostic (SCID) and the Anxiety Disorders Interview Schedule (ADISIV). Low interrater reliability estimates were reported during the 1980s for GAD; however, better estimates have been found using DSM-IV criteria. A recent investigation using the SCID and the ADIS yielded substantial diagnostic agreement for all of the anxiety disorders in an older treatment-seeking sample. Interrater reliability for GAD with the ADIS was similarly found to be excellent. Two additional clinician-rated measures have been used to determine anxiety severity in the elderly. The Hamilton Anxiety Rating Scale (HARS) is a 14-item scale tapping anxiety symptoms in somatic, psychic, and affective domains. In 1997, Beck and Stanley found that the HARS distinguished older adults with GAD from normal controls, providing some preliminary support for the measure. The FEAR is a relatively
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new instrument developed to measure GAD in older adults in the primary care setting. The FEAR, a 4-item version of the 11-item Anxiety Disorder Scale, is meant to be administered verbally during routine medical exams or in the waiting room. The FEAR demonstrated very good sensitivity and specificity in an initial administration to 88 older medical patients, 27% of whom were diagnosed with GAD. Additional psychometric properties of the measure await investigation. There are only a few self-report measures that are recommended for use with late-life GAD patients. The Worry Scale (WS) is a 35-item, self-report questionnaire tapping three subscales of worry domains of importance to older adults—finances, health, social issues—using a 5-point Likert scale. The primary utility of the measure is the assessment of GAD. However, the use of the measure with a sample of older adults with GAD yielded poor convergent validity, with low correlations with other measures of anxiety. The internal reliability estimate was .93, but test–retest reliability was not reported. In a second study by Beck and Stanley in 1997, the measure showed adequate internal reliability and convergent validity. Currently, the properties of this measure seem to be better established in healthy controls than in patient samples. The Penn State Worry Questionnaire (PSWQ) consists of 16 items on a 4-point Likert scale designed to tap the generality, intensity, and uncontrollability of worry. The measure has demonstrated good psychometric properties (e.g., internal consistency, convergent validity) in several studies of older adults with GAD. However, the PSWQ failed to discriminate between older adults with GAD and PD and has shown inadequate test–retest reliability in older GAD patients over a variable period with a mean of 70 days. Stanley and colleagues found that the PSWQ showed good divergent validity with measures of depression. Because late-life GAD is also comorbid with depressive disorders, this is one appealing feature of the measure. The trait scale of the State–Trait Anxiety Inventory (STAI) assesses the tendency to experience frequent anxiety and nervousness. The measure has 20 items on a 4-point Likert scale and is one of the most frequently used self-report questionnaires in studies of anxiety. In heterogeneous older adult samples, the trait scale has shown adequate psychometric properties, and there are ample normative data. In 1996, Stanley, Beck, and Zebb found low to moderate correlations between the STAI and other anxiety and worry measures in older GAD patients but found good internal consistency of .88 for the trait scale. Test–retest
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reliability estimates were not given for the GAD sample but were good in a sample of healthy older adults. A more recent investigation showed good internal consistency but low test–retest reliability (.58) in a sample of 57 older adults with GAD. Mohlman, deJesus, and colleagues found that scores on the measure were very similar in older adults with GAD and PD, suggesting that it taps a nonspecific construct in older samples. s0045
2.1.2. Psychosocial Treatment of Late-Life Generalized Anxiety Disorder Two early studies by Stanley and colleagues indicated that supportive group therapy was beneficial for latelife GAD treatment. The 14-week intervention focused on the discussion of symptoms and experiences and providing support for group members. Investigations of individual format cognitive behavior therapy (CBT) have suggested that this treatment is effective in older adults with GAD. However, it is notable that most of these studies have included nonstandard augmentations to the therapy such as concurrent medication and weekly meetings with a physician, treatment conducted in primary care or in patients’ own homes, and the use of learning aids. The only investigation of standard individual CBT delivered in a mental health clinic indicated very modest efficacy as compared with a wait list condition. Currently, the efficacy of individual CBT is not well supported. Several studies assessing the efficacy of group CBT for late-life GAD indicate that the treatment is typically more effective than wait list control conditions; however, it is not significantly better than other control conditions. Thus, it is possible that nonspecific elements of the group format (e.g., increased social interaction, mitigation of loneliness), rather than elements specific to CBT, led to improvement. Studies comparing group format CBT with individual format CBT should help to clarify this issue.
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2.2. Panic Disorder and Agoraphobia 2.2.1. Assessment Notably, very few studies have addressed the psychometric properties of measures of panic and related symptoms in older patient samples. Two studies, one using a nonclinical community sample and the other using patients drawn from a medical clinic, studied the properties of the Beck Anxiety Inventory (BAI), a well-known
measure of anxiety and panic symptoms and found that the scale had good discriminant validity and internal consistency. The latter study also demonstrated the BAI four-factor solution with autonomic, neuromotor, cognitive, and panic subscales, suggesting that anxiety symptom clusters are slightly different from those found among younger adults. The Anxiety Sensitivity Index (ASI) is a 16-item measure tapping the fear of anxiety sensations, which is known to be a risk factor for the development of panic. In 2000, Mohlman and Zinbarg tested the structure and validity of the ASI in 322 healthy older adults (mean age 75 years). The ASI showed strong internal consistency and moderate correlations with measures of related constructs. Confirmatory factor analysis indicated a hierarchical structure with three group factors—physical concerns, mental incapacitation concerns, and social concerns—as well as a general factor, consistent with previous investigations of the ASI in younger adults. In 1998, Deer and Calamari found that 49% of their older sample (mean age 81 years) reported panic symptoms and that 27% reported a panic attack during the past year. Anxiety sensations predicted unique variance in panic symptomatology and may function as a risk factor for the development of late-life panic.
2.2.2. Psychosocial Treatment of Late-Life Panic Disorder Trials of psychosocial treatments in older samples with PD, panic disorder with agoraphobia (PDA), or agoraphobia without history of panic disorder (AWOHPD) are limited to case studies and three small pilot studies. One study found that principles of reality therapy, which focuses on an individual’s situation and worldview, were effective when used by a neighbor to mitigate an older adult’s paranoia and agoraphobia. Early investigations of behavioral treatments conducted during the 1970s included relaxation, imagery, and exposure. In 1996, Rathus and Sanderson used CBT with two older panic patients: one 70-year-old male and one 69-year-old female. Treatment components were education, cognitive restructuring, interoceptive and situational exposure, and diaphragmatic breathing. Both participants achieved panic-free status and decreased depression following 4 to 5 months of therapy. In 1991, King and Barrowclough tested CBT for panic and anxiety in a small sample of adults ages 66 to 78 years. Of the 10 participants, 8 had primary diagnoses of PDA. After treatment, 7 were free of
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panic and 2 showed decreased symptom severity. Six months later, 8 of the remaining 9 participants were panic free and 6 showed improvement on depression. In 1996, Swales and colleagues tested 10 90-minute sessions of CBT in 15 adults ages 55 to 80 years. Participants experienced decreased severity and frequency of panic attacks, depression, avoidance, and role impairment, and this was apparent at both posttreatment and 3-month follow-up. A reanalysis of Gorenstein and colleagues by Mohlman indicated that CBT plus medication management (n = 5) was somewhat more effective than medication management alone (n = 5) in assisting older adults with PD to decrease anxiety while tapering off anxiolytic medication. The use of interoceptive exposure was believed to facilitate habituation to sensations related to PD and medication withdrawal simultaneously.
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2.3. Social Anxiety Disorder Although the social anxiety literature has grown tremendously during the past several years, there is still a relative dearth of empirical research examining the assessment and treatment of social anxiety in older adults. This may be due in part to the fact that in epidemiological studies, social phobia is a relatively rare disorder among the elderly population. In addition, social anxiety as a distinct diagnostic category did not appear until the third edition of the DSM was published.
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2.3.1. Assessment As noted previously, the SCID and the ADIS-IV are the only two clinician-administered diagnostic instruments with published data on older adults. In 1993, Segal and colleagues reported interrater reliabilities ranging from good to excellent across anxiety disorder diagnoses with use of the SCID. The ADIS-IV is considered the gold standard for diagnosing anxiety disorders in adults. In 2001, Brown and colleagues found the interrater reliability of the lifetime version of this instrument to be excellent for social anxiety on a population of younger adults. Its reliability for diagnosing social phobia in older adults has not yet been established. There are currently a number of self-report measures available for assessing social anxiety in younger adults. Unfortunately, none of the measures that has been used with younger cohorts has norms or other psychometric data supporting its use with older adults.
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2.3.2. Treatment
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In contrast to the abundant literature examining psychological and pharmacological treatment of social anxiety disorder in adults, there are no published studies examining the efficacy or effectiveness of treatments for socially anxious older adults. In 2001, Fedoroff and Taylor conducted a meta-analysis of 108 studies. These researchers compared pharmacological treatments, including selective serotonin reuptake inhibitors (SSRIs), benzodiazepines (BZDs), and monoamine oxidase inhibitors (MAOIs), with components of CBT, including exposure and cognitive restructuring. Studies were included in the analysis if they consisted of at least four patients diagnosed with social anxiety using clinical interviews and consisted of standard treatments of social anxiety. The ages of the patients included in the meta-analysis were not provided, although all studies consisted of adults. Results of the analysis suggested that pharmacotherapies were superior to CBT at posttreatment and that both were superior to controls. BZDs were significantly more effective than both CBT and controls but did not significantly differ from SSRIs. Long-term maintenance of gains was not as well established because many of the studies did not contain sufficient information for estimating this variable. Although these results may have applicability to older adults, the use of BZDs is ventured very cautiously given that this class of medication can cause difficulties with dizziness, respiration, and cognitive functioning. In summary, the literature is scarce regarding effective treatments for social anxiety in older adults. Although both CBT and pharmacotherapy have been proven to be effective treatments, extrapolation to older adults is premature. More research is needed in this area before conclusions can be made concerning best practice treatments of social anxiety treatment in older adults.
2.4. Assessment and Treatment of Obsessive–Compulsive Disorder The observation made by McCarthy and colleagues more than a decade ago, that there is a paucity of research evaluating the efficacy of treatments for older adults diagnosed with OCD, still remains true today. The limited literature that exists has focused primarily either on a variation of CBT called exposure and response/ritual prevention (ERP) or on pharmacological treatment.
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2.4.1. Assessment The assessment literature, with regard to OCD in older adults, offers few recommendations other than the Padua Inventory, which was used with older adults diagnosed with GAD. Some authors have suggested that certain presentations of OCD, such as obsessions and compulsions related to fear of forgetting names and pronounced ego-syntonic scrupulosity, are more likely to occur in the elderly. Besides these case reports, there is little evidence that particular constellations of obsessions and compulsions are unique to older adults. Typical presentations of OCD, such as contamination fears with washing rituals and fears of harming others accompanied by checking compulsions, are also commonly found in the elderly. DSM-IV criteria appear to be appropriate for use with older adults, but more research is needed using structured diagnostic instruments such as the ADIS-IV to better characterize the presentation of OCD in the elderly.
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2.4.2. Treatment Two early uncontrolled case studies of elderly OCD patients reported significant reductions in OCD symptoms following ERP, whereas one anecdotal report documented unsuccessful combined ERP and medication treatments in a 74-year-old woman with OCD and a learning disability. Several controlled outcome studies of ERP using single-case designs yielded similarly successful results. The one study that directly compared treatment responses of older patients with those of younger patients examined the effectiveness of inpatient ERP administered to 10 severely impaired OCD patients age 60 years or over and 10 younger OCD patients matched for gender and clinical severity. No significant differences in response to treatment were found between the older adults and their younger counterparts, with the majorities of both groups being classified as treatment responders at posttreatment. This finding is particularly noteworthy given that the older patients reported having been symptomatic for more than twice as long as the younger adult cohort. In a recent controlled case comparison, Carmin and Wiegartz described two older men with OCD. One experienced a successful outcome and the other experienced an unsuccessful outcome when intensive inpatient ERP was the treatment modality. These authors concluded that the duration of the illness, comorbidity of other psychiatric disorders as well as medical conditions, and the availability of social support can have an effect on treatment outcome.
Cognitive decline can exacerbate or mimic symptoms of OCD, and medical difficulties, such as cerebrovascular accidents (e.g., basal ganglia infarcts), are more prevalent in the elderly and have been noted to produce OCD symptoms in previously healthy patients. Such observations raise the question of whether individuals who have experienced neurological insults that result in OCD can benefit from psychological treatment. Of considerable importance is that ERP and pharmacological treatment were found to be effective in treating a 65-year-old man whose OCD was related to recent basal ganglia infarcts. In comparison with the previously noted studies that used ERP, a follow-up study of medication and supportive psychotherapy that was offered to residents of an old-age home suggested that these methods can have a positive effect on treatment of anxiety disorders, including OCD and panic. One limitation of this study was that this was a diagnostically heterogeneous group, and no details were provided about what medications were used or what supportive psychotherapy entailed. Studies focusing on CBT for late-life OCD have consisted of relatively small patient samples, thereby limiting generalizability. Preliminary findings, however, suggest that late-life OCD is treatable. Even if subsequent research finds lower success rates for the elderly than rates typically reported for the general adult population, there is sufficient evidence to conclude that at least some, if not most, older adults respond to ERP.
2.5. Assessment and Treatment of Posttraumatic Stress Disorder Much of the literature pertaining to posttraumatic stress disorder (PTSD) in the elderly focuses on holocaust and natural disaster victims and combat veterans. Given the vulnerability of older adults to physical violence, there is limited research that examines symptom presentations of elderly crime victims and treatment. Typically, PTSD symptoms in older adults reflect a chronic waxing and waning of symptoms, with exacerbations linked to the expected stressors of advancing age. Despite early studies suggesting a level of resiliency in older adult disaster victims, this resiliency may reflect an underreporting of symptoms by PTSD sufferers, an underdiagnosis by clinicians, or an attribution of anxiety-related somatic symptoms to the normal frailties associated with old age by clinicians, thereby making the accurate diagnosis of this disorder difficult.
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2.5.1. Assessment There are several measures that have been used to assess PTSD symptoms in the elderly. The ClinicianAdministered PTSD Scale (CAPS) is a clinicianadministered semistructured interview that has been used extensively with older individuals who have typically been exposed to war-related trauma. In addition, the CAPS has been used as a process and outcome measure for those experiencing non-combat-related PTSD. These studies suggest that the CAPS is recommended for use with older PTSD sufferers. Although a number of self-report measures have been used to assess PTSD in older adult samples, these studies typically provide descriptive rather than psychometric data. Although the Impact of Events Scale (IES) has provided psychometric data, the findings are equivocal with respect to its use with elders, suggesting that the type of traumatic event may be more important than symptomatology in older samples than in younger samples. The combat and civilian forms of the Mississippi PTSD Scales (MISS) have been significantly correlated with diagnostic measures of PTSD; however, the combat version appears to be the most accurate measure of PTSD severity in a small sample of elderly former prisoners of war.
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2.5.2. Treatment There are two reports of PTSD treatment in older adults. In 1998, Bonwick described a 16-week group day hospital treatment for veterans. The program included elements of psychoeducation, symptom management, relaxation, group therapy, and physical exercise. No outcome data were reported, but the author noted that those receiving treatment reported a greater understanding of PTSD, improved coping skills, and an enhanced quality of life. A recent conceptual review of PTSD in older adults indicates that a better understanding of the issues related to risk and vulnerability to trauma, such as the availability of social support networks, the use of coping strategies, and perceptions of the meaning related to the traumatic event, may allow for a better understanding of how to construct better treatment interventions.
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2.6. Assessment and Treatment of Specific Phobias 2.6.1. Assessment There is surprisingly little information with respect to the assessment and treatment of specific fears in older
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adults given that specific phobias is the most prevalent anxiety disorder in this age group. Of the measures available that assess for the gamut of phobias, the Fear Survey Schedules (FSS-II and FSS-III) have been used with older adults and are promising screening measures for identifying specific fears. Kogan and Edelstein revised this measure specifically for use with older adults (FSS-OA). Their preliminary results are encouraging but not conclusive. One measure, the Falls Efficacy Scale (FES), appears to have good reliability and validity. However, additional psychometric evaluations (e.g., convergent and discriminatory validity) still need to be done before this self-report measure can be used independently of a comprehensive anxiety assessment battery in older persons with somatic symptoms of dizziness or balance disturbances.
2.6.2. Treatment
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There is one randomized controlled study comparing CBT with an educational control group in more than 400 individuals (average age of 77 years) experiencing fears of falling. The CBT patients demonstrated posttreatment gains in mobility control and increased activity, but these gains were lost over a 6-month follow-up period. At 1 year follow-up, the CBT patients showed increased improvement in different areas (e.g., mobility range, social functioning). The authors of this study noted that only 63.4% of their patients attended more than five of the eight offered treatment sessions, thereby highlighting problems with compliance and attrition.
2.7. Issues Related to Anxiety Secondary to a Medical Condition There is considerable overlap between many symptoms diagnostic of an anxiety disorder and symptoms that can be attributed to a medical illness. Medical illnesses such as cardiovascular disease, pulmonary dysfunction, stroke, hyperthyroidism, sensory impairments, and dementia can mimic, exacerbate, antedate, and/or accompany symptoms of anxiety. For example, symptoms of panic may overlap with certain symptoms related to angina, congestive heart failure, or emphysema, causing the diagnosis of panic to be overlooked. Alternatively, the normal developmental changes associated with aging can be mistaken for an anxiety disorder. Individuals who have sensory or mobility impairments may repeatedly check for where a hearing
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aid or walker is located or ask for frequent reassurance, resulting in clinicians mistakenly suggesting a diagnosis of OCD. Clearly, differentiating between anxiety disorders and medical illness in older adults is a complicated task. There are no studies that address the treatment of comorbid anxiety and medical illness.
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3. CONCLUSIONS Enormous strides have been made in the area of the psychopathology, assessment, and treatment of anxiety disorders in adults. Unfortunately, in the area of geriatric anxiety, a tremendous amount of research still needs to be done. There are significant questions as to whether the fundamental nature of anxiety disorders in adults is the same as that during their later years. A further complication arises in that neurobiological changes across the life span were found to cause an age-related decreased cortisol response to an experimental stressor. These findings suggest a decrease in reactivity to stress with advancing years. It has likewise been hypothesized that age-related changes in hypothalamic–pituitary–adrenal (HPA) activity, as indicated by cortisol level, are markers for central nervous system dysfunction. If this is indeed true, anxiety may be a link between central nervous system instability and the increases in cognitive impairment that are often found in aging and may explain the decreased prevalence of anxiety disorders in older adults. As noted previously, epidemiological studies are confounded by their method of sampling. Cohort effects relevant to the stigma attached to mental illness have a greater influence on older adults. Thus, fewer elderly individuals may be willing to endorse anxiety symptoms in the course of an epidemiological study. Likewise, where samples are drawn from may influence prevalence data. Finally, it would appear that both psychosocial and pharmacological treatments appear to aid in the reduction of anxiety symptoms in elderly samples. The prevailing form of psychotherapy that has been studied has been CBT. However, there is not firmly conclusive data that would allow one to unequivocally endorse CBT or a particular medication for use in treating a given anxiety disorder. Clearly, far more research is needed. One optimistic note is that the participants in existing longitudinal studies, such as the Harvard/ Brown Anxiety Research Program (HARP), are aging. Data such as those generated by this study will allow
for the close examination of how anxiety disorders progress over adulthood and into later life and, hopefully, will provide answers to many of the questions that remain regarding geriatric anxiety.
See Also the Following Articles Depression in Late Life n Panic n Personality and Emotion in Late Life n Posttraumatic Disorders n Psychotherapy in Older Adults n Stress
Further Reading American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association. Averill, P. M., & Beck, J. G. (2000). Posttraumatic stress disorder in older adults: A conceptual review. Journal of Anxiety Disorders, 14, 133–156. Ballenger, J. C., Davidson, J. R., Lecrubier, Y., Nutt, D. J., Borkovec, T. D., Rickels, K., Stein, D. J., & Wittchen, H. U. (2001). Consensus statement on generalized anxiety disorder from the International Consensus Group on Depression and Anxiety. Journal of Clinical Psychiatry, 62(Suppl. 11), 53–58. Barrowclough, C., King, P., Colville, J., Russell, E., Burns, A., & Tarrier, N. (2001). A randomized trial of the effectiveness of cognitive–behavioral therapy and supportive counseling for anxiety symptoms in older adults. Journal of Consulting and Clinical Psychology, 69, 756–762. Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893–897. Beck, J. G., & Stanley, M. A. (1997). Anxiety disorders in the elderly: The emerging role of behavior therapy. Behavior Therapy, 28, 83–100. Beck, J. G., Stanley, M. A., & Zebb, B. J. (1996). Characteristics of generalized anxiety disorder in older adults: A descriptive study. Behaviour Research and Therapy, 34, 225–235. Bonwick, R. (1998). Group treatment programme for elderly war veterans with PTSD [letter]. International Journal of Geriatric Psychiatry, 13, 64–65. Brown, T. A., DiNardo, P. A., Lehman, C. L., & Campbell, L. A. (2001). Reliability of DSM-IV anxiety and mood disorders: Implications for the classification of emotional disorders. Journal of Abnormal Psychology, 110, 49–58. Carmin, C. N., Pollard, C. A., & Gillock, K. L. (1999). Assessment of anxiety disorders in the elderly. In P. A. Lichtenberg (Ed.), Handbook of assessment in clinical gerontology (pp. 59–90). New York: John Wiley. Carmin, C. N., Pollard, C. A., & Ownby, R. L. (1998). Obsessive–compulsive disorder: Cognitive behavioral
Anxiety Disorders in Late Life treatment of older versus younger adults. The Clinical Gerontologist, 19(2), 77–81. Carmin, C. N., & Wiegartz, P. S. (2000). Successful and unsuccessful treatment of obsessive–compulsive disorder in older adults. Journal of Contemporary Psychotherapy, 30, 181–193. Carmin, C. N., Wiegartz, P. S., & Scher, C. (2000). Anxiety disorders in the elderly. Current Psychiatry Reports, 2, 13–19. Carmin, C. N., Wiegartz, P. S., Yunus, U., & Gillock, K. L. (2002). Treatment of late-onset OCD following basal ganglia infarct. Depression & Anxiety, 15(2), 87–90. Deer, T. M., & Calamari, J. E. (1998). Panic symptomatology and anxiety sensitivity in older adults. Journal of Behavior Therapy and Experimental Psychiatry, 29, 303–316. Devanand, D. P. (2002). Comorbid psychiatric disorders in late life depression. Biological Psychiatry, 52, 236–242. Fedoroff, I. C., & Taylor, S. (2001). Psychological and pharmacological treatments of social phobia: A meta-analysis. Journal of Clinical Psychopharmacology, 21, 311–324. First, M., Spitzer, R., Gibbon, M., et al. (1995). The Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I, version 2.0, final version). New York: New York State Psychiatric Institute. Flint, A. (1994). Epidemiology and comorbidity of anxiety disorders in the elderly. American Journal of Psychiatry, 151, 640–649. Flint, A. J., Koszycki, D., Vaccarino, F. J., Cadieux, A., Boulenger, J-P., & Bradwejn, J. (1998). Effect of aging on cholecystokinin-induced panic. American Journal of Psychiatry, 155, 283–285. Forsell, Y., & Winblad, B. (1998). Feelings of anxiety and associated variables in a very elderly population. International Journal of Geriatric Psychiatry, 13, 454–458. Gray, J. J., & Acierno, R. (2002). Symptom presentations of older adult crime victims: Description of a clinical sample. Journal of Anxiety Disorders, 16, 299–309. Kabacoff, R. I., Segal, D. L, Hersen, M., & Van Hasselt, V. B. (1997). Psychometric properties and diagnostic utility of the Beck Anxiety Inventory and the State–Trait Anxiety Inventory with older adult psychiatric outpatients. Journal of Anxiety Disorders, 11, 33–47. King, P., & Barrowclough, C. (1991). A clinical pilot study of cognitive–behavioral therapy for anxiety disorders in the elderly. Behavioural Psychotherapy, 19, 337–345. Kogan, J. N., & Edelstein, B. A. (in press). Modification and psychometric examination of a self-report measure of fear in older adults. Journal of Anxiety Disorders. Kogan, J. N., Edelstein, B. A., & McKee, D. R. (2000). Assessment of anxiety in older adults: Current status. Journal of Anxiety Disorders, 14, 109–132. Krasucki, C., Ryan, P., Ertan, T., Howard, R., Lindesay, J., & Mann, A. (1999). The FEAR: A rapid screening instrument for generalized anxiety in elderly primary care attenders. International Journal of Geriatric Psychiatry, 14, 60–68.
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Lindesay, J. (1996). Elderly people and crime. Reviews in Clinical Gerontology, 6, 199–204. Manela, M., Katona, C., & Livingston, G. (1996). How common are the anxiety disorders in old age? International Journal of Geriatric Psychiatry, 11, 65–70. McCarthy, P. R., Katz, I. R., & Foa, E. B. (1991). Cognitive– behavioral treatment of anxiety in the elderly: A proposed model. In C. Salzman, & B. D. Leibowitz (Eds.), Anxiety in the elderly: Treatment and research (pp. 197–214). New York: Springer. Meeks, S., Woodruff-Borden, J., & Depp, C. A. (2003). Structural differentiation of self-reported depression and anxiety in late life. Journal of Anxiety Disorders, 17, 627–646. Mohlman, J., Gorenstein, E. E., Kleber, M., deJesus, M. B., Gorman, J. M., & Papp, L. A. (2003). Standard and enhanced cognitive behavior therapy for late life generalized anxiety disorder: Two pilot investigations. American Journal of Geriatric Psychiatry, 11, 24–32. Mohlman, J., deJesus, M., Gorenstein, E. E., Kleber, M., Gorman, J. M., & Papp, L. A. (in press). Distinguishing generalized anxiety disorder, panic disorder, and mixed anxiety states in older treatment-seeking adults. Journal of Anxiety Disorders. Mohlman, J., & Zinbarg, R. E. (2000). The structure and correlates of anxiety sensitivity in older adults. Psychological Assessment, 12, 440–446. Ownby, R. L., Harwood, G. D., Barker, W. W., & Duara, R. (2000). Predictors of anxiety in patients with Alzheimer’s disease. Depression and Anxiety, 11, 38–42. Radley, M., Redston, C., Bates, F., & Pontefract, M. (1997). Effectiveness of group anxiety management with elderly clients of a community psychogeriatric team. International Journal of Geriatric Psychiatry, 12, 79–84. Rathus, J. H., & Sanderson, W. C. (1996). Cognitive behavioral treatment of panic disorder in elderly adults: Two case studies. Journal of Cognitive Psychotherapy, 10, 271–280. Schaub, R. T., & Linden, M. (2000). Anxiety and anxiety disorders in the old and very old: Results from the Berlin Aging Study (BASE). Comprehensive Psychiatry, 41(2), 48–54. Segal, D. L., Hersen, M., VanHasselt, V. B., Kabacoff, R. L., & Roth, L. (1993). Reliability of diagnosis in older psychiatric patients using the Structured Clinical Interview for DSM-III-R. Journal of Psychopathology and Behavioral Assessment, 15, 347–356. Sheikh, J. I., & Cassidy, E. L. (2000). Treatment of anxiety disorders in the elderly: Issues and strategies. Journal of Anxiety Disorders, 14, 173–190. Snyder, A. G., Stanley, M. A., Novy, D. M., Averill, P. M., & Beck, J. G. (2000). Measures of depression in older adults with generalized anxiety disorder: A psychometric evaluation. Depression and Anxiety, 11, 114–120. Spielberger, C., Gorsuch, R., Lushene, R., Vagg, P., & Jacobs, G. (1983). State–Trait Anxiety Inventory: Test manual. Palo Alto, CA: Consulting Psychologists Press.
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Stanley, M. A., & Beck, J. G. (2000). Anxiety disorders. Clinical Psychology Review, 20, 731–754. Stanley, M. A., Beck, J. G., Barron, M., & Wagner, A. L. (1994, November). Treatment of generalized anxiety disorder in older adults: Examination of outcome predictors. Paper presented at the annual meeting of the Association for the Advancement of Behavior Therapy, San Diego. Stanley, M. A., Beck, J. G., & Glassco, J. D. (1996). Treatment of generalized anxiety in older adults: A preliminary comparison of cognitive–behavioral and supportive approaches. Behavior Therapy, 27, 565–581. Stanley, M. A., Beck, J. G., Novy, D. M., Averill, P. M., Swann, A. C., Diefenbach, G. J., & Hopko, D. (2003). Cognitive behavioral treatment of late-life generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 71, 309–319. Stanley, M. A., Beck, J. G., & Zebb, B. J. (1996). Psychometric properties of four anxiety measures in older adults. Behaviour Research and Therapy, 34, 827–838.
Stanley, M. A., Novy, D. M., Bourland, S. L., Beck, J. G., & Averill, P. M. (2001). Assessing older adults with generalized anxiety: A replication and extension. Behaviour Research and Therapy, 39, 221–235. Swales, P., Solfrin, J., & Sheikh, J. (1996). Cognitive behaviour therapy in older panic disorder patients. American Journal of Geriatric Psychiatry, 4, 46–60. Swartz, M., Martin, T., Martin, M., Eizur, A., & Barak, Y. (1999). Outcome of a psychogeriatric intervention in an old-age home: A 3 year follow-up study. Annals of Clinical Psychiatry, 11, 109–112. Van Balkom, A. J., Beekman, A. T., De Beurs, E., Deeg, D. J., Van Dyck, R., & Van Tilburg, W. (2000). Comorbidity of the anxiety disorders in a community-based older population in The Netherlands. Acta Psychiatrica Scandinavica, 101, 37–45. Wetherell, J. L., Gatz, M., & Craske, M. G. (2003). Treatment of generalized anxiety disorder in older adults. Journal of Consulting and Clinical Psychology, 71, 31–40.
Anxiety Disorders in Late Life Cheryl N. Carmin
Jan Mohlman
Amy Buckley
University of Illinois at Chicago, Illinois, USA
Syracuse University, Syracuse, New York, USA
University of Illinois at Chicago, Illinois, USA
1. Epidemiology of Anxiety Disorders in Older Adults 2. Assessment and Treatment of Anxiety Disorders 3. Conclusions Further Reading
GLOSSARY cognitive behavior therapy A collaborative form of psychotherapy that involves facilitating patients’ changing their belief system via a Socratic dialogue focusing on those distressing thoughts that exacerbate negative emotions and maladaptive behaviors. ego-syntonic/ego-dystonic obsessions Terms typically used in describing whether obsessions are congruent or incongruent with one’s beliefs; an ego-dystonic obsession may include the belief that washing one’s hands for 15 minutes will prevent cancer with the understanding that, despite the persistence of the thought, it is illogical. epidemiology A branch of medical science that deals with the incidence/prevalence, distribution, and prevention of a disease or condition as well as the identification of atrisk populations. Likert scale A means of assigning a numerical intensity rating that is anchored by descriptive terms to a construct (e.g., I would describe my worry as 1 = very mild, 2 = mild, 3 = average, 4 = excessive, 5 = very excessive).
Recent epidemiological studies have underscored the ubiquitous nature of anxiety disorders, with
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approximately 25% of adults being affected over the course of their lifetimes. Furthermore, the economic burden of these disorders has been estimated at $42.3 billion, comprising 31% of psychiatric treatment costs. Given the prevalence of anxiety disorders, it is not surprising that an increasing amount of attention has been given to investigating the prevalence and treatment of these conditions. What is surprising, however, is how little attention has been given to anxiety disorders in what is the fastest growing segment of the population, namely the elderly. This article summarizes how the existing research literature informs us with respect to the epidemiology of anxiety disorders in the elderly and then examines the treatment outcome literature with regard to the individual anxiety disorders.
1. EPIDEMIOLOGY OF ANXIETY DISORDERS IN OLDER ADULTS The United States is aging. The U.S. Census Bureau predicts that more than 72 million adults will be age 65 years or over by the year 2030. Recent epidemiological studies underscore that anxiety disorders are the most prominent of the psychiatric conditions, with lifetime estimates nearing 25%. Despite the widespread prevalence and extensive cost to society of anxiety disorders, there is currently little data on the rate and phenomenology of anxiety disorders in the elderly population.
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1.1. General Prevalence Data It is generally believed that anxiety disorders occur less frequently in the elderly population than in younger adults. However, there have been only a small number of epidemiological studies that have tested this contention directly. A recent epidemiological study in the United States that included persons over 65 years of age is the Epidemiological Catchment Area (ECA) study, which included more than 18,000 noninstitutionalized adults. The ECA study systematically examined the rate of anxiety disorders at five sites across the country. Fully 30% of the ECA subjects were age 65 years or over. It was ascertained that the 1-month prevalence rate of anxiety disorders in the elderly was approximately 5.5%, lower than the 7.3% estimate for all adults surveyed. Furthermore, elderly women were nearly twice as likely to have anxiety disorders as were elderly men. The percentage of elderly adults with anxiety disorders was higher than that with any other psychiatric illness, including cognitive impairment, underscoring the need for appropriate identification and treatment in this population. Furthermore, rates of anxiety disorders were much higher than the 2.5% prevalence rate of affective disorders in this population. Other reviews of smaller scale epidemiological studies found that rates of anxiety disorders ranged between 0.7 and 19.0%. Similar 6-month prevalence rates of 3.5% have been found in Europe.
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the prevalence of GAD are not included in the ECA data and that other studies that find higher prevalence rates of GAD may be due to differences in their respective methodologies, for example, the decision rules applied in rendering a diagnosis.
1.3. Reliability of Epidemiological Studies
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There are several potential explanations for the wide variability of estimates of anxiety disorder prevalence in the elderly. The existing epidemiological studies use different methodologies, and this often makes it difficult to compare prevalence rates across individual studies. Some of the studies include institutionalized elderly adults, whereas others survey communitydwelling residents only. In addition, measures of anxiety symptoms validated on younger adults might not be applicable to older adults given that the experience and expression of anxiety may change with age. Likewise, the instruments used to assess anxiety in older adults might not have norms or other psychometric data that are established for older adults, let alone for very old adults. Further research is needed to delineate factors that contribute to the difference in prevalence estimates and to clarify the nature of anxiety in the elderly. Until then, estimates of prevalence rates of anxiety disorders in the elderly should be considered preliminary.
1.2. Epidemiology of Individual Anxiety Disorders
1.4. Comorbidity
Rates for specific anxiety disorders also vary across studies and differ between elderly males and females. Data from the ECA study suggest that phobias are the most frequently experienced anxiety disorder in the elderly, affecting an estimated 4.8% of older adults. Panic disorder (PD) and obsessive–compulsive disorder (OCD) in the elderly population are expected to occur only infrequently. Rates for PD are estimated to not exceed 0.3%, and when panic does occur in elderly adults, it tends to be in women. Similarly, rates of OCD among the elderly are low, with prevalence estimates being 3.5% at a maximum and with elderly adults residing in institutional settings accounting for the upper end of these prevalence estimates. Data regarding the prevalence of generalized anxiety disorder (GAD) suggest that it has a much more variable occurrence in the elderly population, ranging between 0.7 and 7.1%. It is important to note that data on
It is well known in the literature that anxiety disorders often co-occur with other diagnoses, including depression and other anxiety disorders. However, it is important to examine whether this is true for elderly persons as well. Research is beginning to shed light on the co-occurrence of anxiety and other psychiatric disorders in older adults. As with younger adults, depression most frequently co-occurs with anxiety disorders among elderly patients. In addition, when depression is the primary diagnosis in elderly adults, anxiety frequently co-occurs. In general, the delineation between depression and anxiety is not clear, and research suggests that it might be even less clear for older adults. Unlike anxiety or depression, the incidence of cognitive impairment increases with age. Research examining the relationship between anxiety and dementia in older adults typically finds that these syndromes often coexist. Symptoms of anxiety often occur in the
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context of dementia as well as in nondemented older adults. In summary, although the frequency with which anxiety disorders are present in older adults is lower than that in younger adults, these data may be confounded by methodological problems such as differences in diagnostic classification, commonalities between anxiety and depression in this population, and the frequent occurrence of anxiety symptoms accompanying medical conditions.
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2. ASSESSMENT AND TREATMENT OF ANXIETY DISORDERS
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2.1. Generalized Anxiety Disorder
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2.1.1. Assessment Diagnostic criteria for GAD have undergone considerable revision over the past 20 years or so. The most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) emphasizes chronic uncontrollable worry that causes significant distress or impairment as the hallmark symptom of the disorder. In adults of all ages, GAD is most often comorbid with other affective and anxiety disorders and is sometimes viewed as a vulnerability factor for the development of additional psychiatric problems. GAD is often secondary to depressive disorders in older adults. As noted by Carmin and colleagues in 1999, the only clinician-rated diagnostic interviews that have been found to yield reliable diagnoses with elderly patients are the Structured Clinical Interview Diagnostic (SCID) and the Anxiety Disorders Interview Schedule (ADISIV). Low interrater reliability estimates were reported during the 1980s for GAD; however, better estimates have been found using DSM-IV criteria. A recent investigation using the SCID and the ADIS yielded substantial diagnostic agreement for all of the anxiety disorders in an older treatment-seeking sample. Interrater reliability for GAD with the ADIS was similarly found to be excellent. Two additional clinician-rated measures have been used to determine anxiety severity in the elderly. The Hamilton Anxiety Rating Scale (HARS) is a 14-item scale tapping anxiety symptoms in somatic, psychic, and affective domains. In 1997, Beck and Stanley found that the HARS distinguished older adults with GAD from normal controls, providing some preliminary support for the measure. The FEAR is a relatively
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new instrument developed to measure GAD in older adults in the primary care setting. The FEAR, a 4-item version of the 11-item Anxiety Disorder Scale, is meant to be administered verbally during routine medical exams or in the waiting room. The FEAR demonstrated very good sensitivity and specificity in an initial administration to 88 older medical patients, 27% of whom were diagnosed with GAD. Additional psychometric properties of the measure await investigation. There are only a few self-report measures that are recommended for use with late-life GAD patients. The Worry Scale (WS) is a 35-item, self-report questionnaire tapping three subscales of worry domains of importance to older adults—finances, health, social issues—using a 5-point Likert scale. The primary utility of the measure is the assessment of GAD. However, the use of the measure with a sample of older adults with GAD yielded poor convergent validity, with low correlations with other measures of anxiety. The internal reliability estimate was .93, but test–retest reliability was not reported. In a second study by Beck and Stanley in 1997, the measure showed adequate internal reliability and convergent validity. Currently, the properties of this measure seem to be better established in healthy controls than in patient samples. The Penn State Worry Questionnaire (PSWQ) consists of 16 items on a 4-point Likert scale designed to tap the generality, intensity, and uncontrollability of worry. The measure has demonstrated good psychometric properties (e.g., internal consistency, convergent validity) in several studies of older adults with GAD. However, the PSWQ failed to discriminate between older adults with GAD and PD and has shown inadequate test–retest reliability in older GAD patients over a variable period with a mean of 70 days. Stanley and colleagues found that the PSWQ showed good divergent validity with measures of depression. Because late-life GAD is also comorbid with depressive disorders, this is one appealing feature of the measure. The trait scale of the State–Trait Anxiety Inventory (STAI) assesses the tendency to experience frequent anxiety and nervousness. The measure has 20 items on a 4-point Likert scale and is one of the most frequently used self-report questionnaires in studies of anxiety. In heterogeneous older adult samples, the trait scale has shown adequate psychometric properties, and there are ample normative data. In 1996, Stanley, Beck, and Zebb found low to moderate correlations between the STAI and other anxiety and worry measures in older GAD patients but found good internal consistency of .88 for the trait scale. Test–retest
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reliability estimates were not given for the GAD sample but were good in a sample of healthy older adults. A more recent investigation showed good internal consistency but low test–retest reliability (.58) in a sample of 57 older adults with GAD. Mohlman, deJesus, and colleagues found that scores on the measure were very similar in older adults with GAD and PD, suggesting that it taps a nonspecific construct in older samples. s0045
2.1.2. Psychosocial Treatment of Late-Life Generalized Anxiety Disorder Two early studies by Stanley and colleagues indicated that supportive group therapy was beneficial for latelife GAD treatment. The 14-week intervention focused on the discussion of symptoms and experiences and providing support for group members. Investigations of individual format cognitive behavior therapy (CBT) have suggested that this treatment is effective in older adults with GAD. However, it is notable that most of these studies have included nonstandard augmentations to the therapy such as concurrent medication and weekly meetings with a physician, treatment conducted in primary care or in patients’ own homes, and the use of learning aids. The only investigation of standard individual CBT delivered in a mental health clinic indicated very modest efficacy as compared with a wait list condition. Currently, the efficacy of individual CBT is not well supported. Several studies assessing the efficacy of group CBT for late-life GAD indicate that the treatment is typically more effective than wait list control conditions; however, it is not significantly better than other control conditions. Thus, it is possible that nonspecific elements of the group format (e.g., increased social interaction, mitigation of loneliness), rather than elements specific to CBT, led to improvement. Studies comparing group format CBT with individual format CBT should help to clarify this issue.
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2.2. Panic Disorder and Agoraphobia 2.2.1. Assessment Notably, very few studies have addressed the psychometric properties of measures of panic and related symptoms in older patient samples. Two studies, one using a nonclinical community sample and the other using patients drawn from a medical clinic, studied the properties of the Beck Anxiety Inventory (BAI), a well-known
measure of anxiety and panic symptoms and found that the scale had good discriminant validity and internal consistency. The latter study also demonstrated the BAI four-factor solution with autonomic, neuromotor, cognitive, and panic subscales, suggesting that anxiety symptom clusters are slightly different from those found among younger adults. The Anxiety Sensitivity Index (ASI) is a 16-item measure tapping the fear of anxiety sensations, which is known to be a risk factor for the development of panic. In 2000, Mohlman and Zinbarg tested the structure and validity of the ASI in 322 healthy older adults (mean age 75 years). The ASI showed strong internal consistency and moderate correlations with measures of related constructs. Confirmatory factor analysis indicated a hierarchical structure with three group factors—physical concerns, mental incapacitation concerns, and social concerns—as well as a general factor, consistent with previous investigations of the ASI in younger adults. In 1998, Deer and Calamari found that 49% of their older sample (mean age 81 years) reported panic symptoms and that 27% reported a panic attack during the past year. Anxiety sensations predicted unique variance in panic symptomatology and may function as a risk factor for the development of late-life panic.
2.2.2. Psychosocial Treatment of Late-Life Panic Disorder Trials of psychosocial treatments in older samples with PD, panic disorder with agoraphobia (PDA), or agoraphobia without history of panic disorder (AWOHPD) are limited to case studies and three small pilot studies. One study found that principles of reality therapy, which focuses on an individual’s situation and worldview, were effective when used by a neighbor to mitigate an older adult’s paranoia and agoraphobia. Early investigations of behavioral treatments conducted during the 1970s included relaxation, imagery, and exposure. In 1996, Rathus and Sanderson used CBT with two older panic patients: one 70-year-old male and one 69-year-old female. Treatment components were education, cognitive restructuring, interoceptive and situational exposure, and diaphragmatic breathing. Both participants achieved panic-free status and decreased depression following 4 to 5 months of therapy. In 1991, King and Barrowclough tested CBT for panic and anxiety in a small sample of adults ages 66 to 78 years. Of the 10 participants, 8 had primary diagnoses of PDA. After treatment, 7 were free of
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panic and 2 showed decreased symptom severity. Six months later, 8 of the remaining 9 participants were panic free and 6 showed improvement on depression. In 1996, Swales and colleagues tested 10 90-minute sessions of CBT in 15 adults ages 55 to 80 years. Participants experienced decreased severity and frequency of panic attacks, depression, avoidance, and role impairment, and this was apparent at both posttreatment and 3-month follow-up. A reanalysis of Gorenstein and colleagues by Mohlman indicated that CBT plus medication management (n = 5) was somewhat more effective than medication management alone (n = 5) in assisting older adults with PD to decrease anxiety while tapering off anxiolytic medication. The use of interoceptive exposure was believed to facilitate habituation to sensations related to PD and medication withdrawal simultaneously.
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2.3. Social Anxiety Disorder Although the social anxiety literature has grown tremendously during the past several years, there is still a relative dearth of empirical research examining the assessment and treatment of social anxiety in older adults. This may be due in part to the fact that in epidemiological studies, social phobia is a relatively rare disorder among the elderly population. In addition, social anxiety as a distinct diagnostic category did not appear until the third edition of the DSM was published.
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2.3.1. Assessment As noted previously, the SCID and the ADIS-IV are the only two clinician-administered diagnostic instruments with published data on older adults. In 1993, Segal and colleagues reported interrater reliabilities ranging from good to excellent across anxiety disorder diagnoses with use of the SCID. The ADIS-IV is considered the gold standard for diagnosing anxiety disorders in adults. In 2001, Brown and colleagues found the interrater reliability of the lifetime version of this instrument to be excellent for social anxiety on a population of younger adults. Its reliability for diagnosing social phobia in older adults has not yet been established. There are currently a number of self-report measures available for assessing social anxiety in younger adults. Unfortunately, none of the measures that has been used with younger cohorts has norms or other psychometric data supporting its use with older adults.
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2.3.2. Treatment
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In contrast to the abundant literature examining psychological and pharmacological treatment of social anxiety disorder in adults, there are no published studies examining the efficacy or effectiveness of treatments for socially anxious older adults. In 2001, Fedoroff and Taylor conducted a meta-analysis of 108 studies. These researchers compared pharmacological treatments, including selective serotonin reuptake inhibitors (SSRIs), benzodiazepines (BZDs), and monoamine oxidase inhibitors (MAOIs), with components of CBT, including exposure and cognitive restructuring. Studies were included in the analysis if they consisted of at least four patients diagnosed with social anxiety using clinical interviews and consisted of standard treatments of social anxiety. The ages of the patients included in the meta-analysis were not provided, although all studies consisted of adults. Results of the analysis suggested that pharmacotherapies were superior to CBT at posttreatment and that both were superior to controls. BZDs were significantly more effective than both CBT and controls but did not significantly differ from SSRIs. Long-term maintenance of gains was not as well established because many of the studies did not contain sufficient information for estimating this variable. Although these results may have applicability to older adults, the use of BZDs is ventured very cautiously given that this class of medication can cause difficulties with dizziness, respiration, and cognitive functioning. In summary, the literature is scarce regarding effective treatments for social anxiety in older adults. Although both CBT and pharmacotherapy have been proven to be effective treatments, extrapolation to older adults is premature. More research is needed in this area before conclusions can be made concerning best practice treatments of social anxiety treatment in older adults.
2.4. Assessment and Treatment of Obsessive–Compulsive Disorder The observation made by McCarthy and colleagues more than a decade ago, that there is a paucity of research evaluating the efficacy of treatments for older adults diagnosed with OCD, still remains true today. The limited literature that exists has focused primarily either on a variation of CBT called exposure and response/ritual prevention (ERP) or on pharmacological treatment.
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2.4.1. Assessment The assessment literature, with regard to OCD in older adults, offers few recommendations other than the Padua Inventory, which was used with older adults diagnosed with GAD. Some authors have suggested that certain presentations of OCD, such as obsessions and compulsions related to fear of forgetting names and pronounced ego-syntonic scrupulosity, are more likely to occur in the elderly. Besides these case reports, there is little evidence that particular constellations of obsessions and compulsions are unique to older adults. Typical presentations of OCD, such as contamination fears with washing rituals and fears of harming others accompanied by checking compulsions, are also commonly found in the elderly. DSM-IV criteria appear to be appropriate for use with older adults, but more research is needed using structured diagnostic instruments such as the ADIS-IV to better characterize the presentation of OCD in the elderly.
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2.4.2. Treatment Two early uncontrolled case studies of elderly OCD patients reported significant reductions in OCD symptoms following ERP, whereas one anecdotal report documented unsuccessful combined ERP and medication treatments in a 74-year-old woman with OCD and a learning disability. Several controlled outcome studies of ERP using single-case designs yielded similarly successful results. The one study that directly compared treatment responses of older patients with those of younger patients examined the effectiveness of inpatient ERP administered to 10 severely impaired OCD patients age 60 years or over and 10 younger OCD patients matched for gender and clinical severity. No significant differences in response to treatment were found between the older adults and their younger counterparts, with the majorities of both groups being classified as treatment responders at posttreatment. This finding is particularly noteworthy given that the older patients reported having been symptomatic for more than twice as long as the younger adult cohort. In a recent controlled case comparison, Carmin and Wiegartz described two older men with OCD. One experienced a successful outcome and the other experienced an unsuccessful outcome when intensive inpatient ERP was the treatment modality. These authors concluded that the duration of the illness, comorbidity of other psychiatric disorders as well as medical conditions, and the availability of social support can have an effect on treatment outcome.
Cognitive decline can exacerbate or mimic symptoms of OCD, and medical difficulties, such as cerebrovascular accidents (e.g., basal ganglia infarcts), are more prevalent in the elderly and have been noted to produce OCD symptoms in previously healthy patients. Such observations raise the question of whether individuals who have experienced neurological insults that result in OCD can benefit from psychological treatment. Of considerable importance is that ERP and pharmacological treatment were found to be effective in treating a 65-year-old man whose OCD was related to recent basal ganglia infarcts. In comparison with the previously noted studies that used ERP, a follow-up study of medication and supportive psychotherapy that was offered to residents of an old-age home suggested that these methods can have a positive effect on treatment of anxiety disorders, including OCD and panic. One limitation of this study was that this was a diagnostically heterogeneous group, and no details were provided about what medications were used or what supportive psychotherapy entailed. Studies focusing on CBT for late-life OCD have consisted of relatively small patient samples, thereby limiting generalizability. Preliminary findings, however, suggest that late-life OCD is treatable. Even if subsequent research finds lower success rates for the elderly than rates typically reported for the general adult population, there is sufficient evidence to conclude that at least some, if not most, older adults respond to ERP.
2.5. Assessment and Treatment of Posttraumatic Stress Disorder Much of the literature pertaining to posttraumatic stress disorder (PTSD) in the elderly focuses on holocaust and natural disaster victims and combat veterans. Given the vulnerability of older adults to physical violence, there is limited research that examines symptom presentations of elderly crime victims and treatment. Typically, PTSD symptoms in older adults reflect a chronic waxing and waning of symptoms, with exacerbations linked to the expected stressors of advancing age. Despite early studies suggesting a level of resiliency in older adult disaster victims, this resiliency may reflect an underreporting of symptoms by PTSD sufferers, an underdiagnosis by clinicians, or an attribution of anxiety-related somatic symptoms to the normal frailties associated with old age by clinicians, thereby making the accurate diagnosis of this disorder difficult.
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2.5.1. Assessment There are several measures that have been used to assess PTSD symptoms in the elderly. The ClinicianAdministered PTSD Scale (CAPS) is a clinicianadministered semistructured interview that has been used extensively with older individuals who have typically been exposed to war-related trauma. In addition, the CAPS has been used as a process and outcome measure for those experiencing non-combat-related PTSD. These studies suggest that the CAPS is recommended for use with older PTSD sufferers. Although a number of self-report measures have been used to assess PTSD in older adult samples, these studies typically provide descriptive rather than psychometric data. Although the Impact of Events Scale (IES) has provided psychometric data, the findings are equivocal with respect to its use with elders, suggesting that the type of traumatic event may be more important than symptomatology in older samples than in younger samples. The combat and civilian forms of the Mississippi PTSD Scales (MISS) have been significantly correlated with diagnostic measures of PTSD; however, the combat version appears to be the most accurate measure of PTSD severity in a small sample of elderly former prisoners of war.
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2.5.2. Treatment There are two reports of PTSD treatment in older adults. In 1998, Bonwick described a 16-week group day hospital treatment for veterans. The program included elements of psychoeducation, symptom management, relaxation, group therapy, and physical exercise. No outcome data were reported, but the author noted that those receiving treatment reported a greater understanding of PTSD, improved coping skills, and an enhanced quality of life. A recent conceptual review of PTSD in older adults indicates that a better understanding of the issues related to risk and vulnerability to trauma, such as the availability of social support networks, the use of coping strategies, and perceptions of the meaning related to the traumatic event, may allow for a better understanding of how to construct better treatment interventions.
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2.6. Assessment and Treatment of Specific Phobias 2.6.1. Assessment There is surprisingly little information with respect to the assessment and treatment of specific fears in older
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adults given that specific phobias is the most prevalent anxiety disorder in this age group. Of the measures available that assess for the gamut of phobias, the Fear Survey Schedules (FSS-II and FSS-III) have been used with older adults and are promising screening measures for identifying specific fears. Kogan and Edelstein revised this measure specifically for use with older adults (FSS-OA). Their preliminary results are encouraging but not conclusive. One measure, the Falls Efficacy Scale (FES), appears to have good reliability and validity. However, additional psychometric evaluations (e.g., convergent and discriminatory validity) still need to be done before this self-report measure can be used independently of a comprehensive anxiety assessment battery in older persons with somatic symptoms of dizziness or balance disturbances.
2.6.2. Treatment
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There is one randomized controlled study comparing CBT with an educational control group in more than 400 individuals (average age of 77 years) experiencing fears of falling. The CBT patients demonstrated posttreatment gains in mobility control and increased activity, but these gains were lost over a 6-month follow-up period. At 1 year follow-up, the CBT patients showed increased improvement in different areas (e.g., mobility range, social functioning). The authors of this study noted that only 63.4% of their patients attended more than five of the eight offered treatment sessions, thereby highlighting problems with compliance and attrition.
2.7. Issues Related to Anxiety Secondary to a Medical Condition There is considerable overlap between many symptoms diagnostic of an anxiety disorder and symptoms that can be attributed to a medical illness. Medical illnesses such as cardiovascular disease, pulmonary dysfunction, stroke, hyperthyroidism, sensory impairments, and dementia can mimic, exacerbate, antedate, and/or accompany symptoms of anxiety. For example, symptoms of panic may overlap with certain symptoms related to angina, congestive heart failure, or emphysema, causing the diagnosis of panic to be overlooked. Alternatively, the normal developmental changes associated with aging can be mistaken for an anxiety disorder. Individuals who have sensory or mobility impairments may repeatedly check for where a hearing
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aid or walker is located or ask for frequent reassurance, resulting in clinicians mistakenly suggesting a diagnosis of OCD. Clearly, differentiating between anxiety disorders and medical illness in older adults is a complicated task. There are no studies that address the treatment of comorbid anxiety and medical illness.
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3. CONCLUSIONS Enormous strides have been made in the area of the psychopathology, assessment, and treatment of anxiety disorders in adults. Unfortunately, in the area of geriatric anxiety, a tremendous amount of research still needs to be done. There are significant questions as to whether the fundamental nature of anxiety disorders in adults is the same as that during their later years. A further complication arises in that neurobiological changes across the life span were found to cause an age-related decreased cortisol response to an experimental stressor. These findings suggest a decrease in reactivity to stress with advancing years. It has likewise been hypothesized that age-related changes in hypothalamic–pituitary–adrenal (HPA) activity, as indicated by cortisol level, are markers for central nervous system dysfunction. If this is indeed true, anxiety may be a link between central nervous system instability and the increases in cognitive impairment that are often found in aging and may explain the decreased prevalence of anxiety disorders in older adults. As noted previously, epidemiological studies are confounded by their method of sampling. Cohort effects relevant to the stigma attached to mental illness have a greater influence on older adults. Thus, fewer elderly individuals may be willing to endorse anxiety symptoms in the course of an epidemiological study. Likewise, where samples are drawn from may influence prevalence data. Finally, it would appear that both psychosocial and pharmacological treatments appear to aid in the reduction of anxiety symptoms in elderly samples. The prevailing form of psychotherapy that has been studied has been CBT. However, there is not firmly conclusive data that would allow one to unequivocally endorse CBT or a particular medication for use in treating a given anxiety disorder. Clearly, far more research is needed. One optimistic note is that the participants in existing longitudinal studies, such as the Harvard/ Brown Anxiety Research Program (HARP), are aging. Data such as those generated by this study will allow
for the close examination of how anxiety disorders progress over adulthood and into later life and, hopefully, will provide answers to many of the questions that remain regarding geriatric anxiety.
See Also the Following Articles Depression in Late Life n Panic n Personality and Emotion in Late Life n Posttraumatic Disorders n Psychotherapy in Older Adults n Stress
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