Anxiety disorders in non-demented and demented elderly patients: prevalence and correlates

The Relationship between Oxidative Stress and Anxiety in a Healthy Older Population

Background/study context: F₂-Isoprostanes are putative markers of oxidative stress, one of the processes associated with biological senescence. Evidence exists for elevated F₂-Isoprostanes in chronic conditions including psychiatric disorders. Few studies have examined the relationship between oxidative stress and mood in older healthy samples, to establish the influence on mental health. Given current aging demographics in many nations, management of brain and mental health is crucial for longevity, chronic disease management, and quality of life.Method: We investigated the relationship between F₂-Isoprostanes, a marker for oxidative stress, and anxiety and mood in 262 healthy adults aged 60-75 years, using baseline data from the Australian Research Council Longevity Intervention (ARCLI; ANZCTR12611000487910), a 12-month nutraceutical intervention study.Results: Higher F2 levels significantly predicted increased Depression-dejection and Anger-hostility subscale scores from the Profile of Mood States (POMS). Fatigue-inertia subscale was predicted by increased Body Mass Index. Spielberger State-Trait Inventory (STAI) scores were significantly higher in females.Conclusion: While the primary outcome data did not find a definitive relationship between F2 and total mood or general anxiety levels, the sub-scale data adds weight toward growing literature that biological processes such as oxidative stress are in part related to mood. This is a modifiable risk factor contributing to physical and mental wellbeing that are crucial to healthy aging.

Anxiety symptoms predicted decline in episodic memory in cognitively healthy older adults: A 3-year prospective study

OBJECTIVE

Prospective studies on late-life anxiety disorders suggested that history of anxiety symptoms may be predictive of cognitive decline in old age. However, the relationship between anxiety and cognitive decline is still inconclusive due to heterogeneity in sample and methodology. This study was to explore how baseline anxiety symptoms associated with the change of memory in older people without cognitive impairment over a 3-year period.

METHODS

This was a 3-year prospective study on 91 cognitively normal older adults with anxiety symptoms. They were matched with 91 controls based on age, gender, and education. Anxiety symptoms were assessed with Revised Clinical Interview Schedule (CIS-R). Physical health was assessed with Chronic Illness Rating Scale (CIRS). Cognitive performance was measured using Cantonese version of the mini-mental state examination (CMMSE); 10-minute delay recall; Category verbal fluency test (CVFT); Trail making tests (TMT); and digit and visual span tests. Outcomes were determined as the change of cognitive performance over a 3-year period.

RESULTS

As expected, anxiety group had higher score in CIRS score (t = 4.45, P < .001) and CIS-R score (t = 9.24, P < .001) than control group. Linear regression showed that baseline anxiety symptoms were associated with change in delayed recall (B = 0.77, P = 0.027, 95% CI = 0.09-1.46), after adjusting for cognitive performance, physical, and mental health statuses.

CONCLUSIONS

Anxious healthy older adults showed specific decline in episodic memory over a 3-year interval. Our result suggested that anxiety symptoms are predictive of episodic memory decline in cognitively healthy older adults and may be an early sign of neurodegenerative disorders.

The prevalence, reporting, and treatment of anxiety among older adults in nursing homes and other residential aged care facilities

BACKGROUND

Little is known about anxiety in aged care populations, despite its increase in this frail population. This study investigated the prevalence, recording, and treatment rate of anxiety disorders among aged care residents.

METHODS

A cross-sectional, observational design was used to assess 180 elderly residents from 12 aged care facilities in Melbourne, Australia. Participants were assessed for threshold and subthreshold anxiety disorders and comorbid depression using the MINI for DSM-5. Medical files were also reviewed to determine whether there was any indication that anxiety had previously been detected, and what treatment those with a threshold/subthreshold diagnosis were receiving.

RESULTS

Overall prevalence of threshold and subthreshold anxiety disorders was 19.4% and 11.7%, respectively. Generalized anxiety disorder was the most common threshold disorder and agoraphobia was the most prevalent subthreshold anxiety disorder. While less than half of those with a threshold or subthreshold anxiety disorder had an indication of anxiety in their file, the majority received psychotropic medication. Cognitive impairment was not significantly associated with the prevalence or treatment of anxiety.

CONCLUSIONS

The prevalence of threshold and subthreshold anxiety in aged care settings is high, but remains under-reported by staff and GPs. Facility staff and GPs should ensure they are aware of how anxiety presents in elderly residents and routinely screen for this common mental health issue. This cohort had poor access to psychological treatments for their condition.

Effects of Home-Delivered Cognitive Behavioral Therapy (CBT) for Depression on Anxiety Symptoms among Rural, Ethnically Diverse Older Adults

BACKGROUND

We examined the effects of home-delivered cognitive-behavioral therapy (CBT) for depression on anxiety symptoms in an ethnically diverse, low resource, and medically frail sample of rural, older adults.

METHOD

This was a secondary analysis of a randomized clincial trial with 134 rural-dwelling adults 65 years and older with decreased quality of life and elevated psychological symptomatology. Anxiety symptoms were assessed with the anxiety and phobic anxiety subscales of the Symptom Checklist-90-Revised (SCL-90-R).

RESULTS

Compared to a minimal support control condition, CBT for depression resulted in significantly greater improvements in symptoms of anxiety and phobic anxiety from pre-treatment to post-treatment.

CONCLUSION

Home-delivered CBT for depression can be an effective treatment for anxiety in a hard-to-reach older populations.

CLINICAL IMPLICATIONS

Additional research should explore integrated anxiety and depression protocols and other treatment modalities, including bibliotherapy or telehealth models of CBT, to reduce costs associated with its in home delivery. Flexibility in administration and adaptations to the CBT protocol may be necessary for use with vulnerable, rural older adults.

Peripheral Nerve Blocks for the Treatment of Headache in Older Adults: A Retrospective Study

OBJECTIVE

The objective of this study is to provide demographical and clinical descriptions of patients age 65 years old and older who were treated with peripheral nerve blocks (PNBs) at our institution and evaluate the safety and efficacy of this treatment.

BACKGROUND

Headache disorders are common, disabling chronic neurological diseases that often persist with advancing age. Geriatric headache management poses unique therapeutic challenges because of considerations of comorbidity, drug interactions, and adverse effects. Peripheral nerve blocks are commonly used for acute and short-term prophylactic treatment for headache disorders and may be a safer alternative to standard pharmacotherapy in this demographic.

DESIGN

We performed a single center, retrospective chart review of patients at least 65 years of age who received peripheral nerve blocks for headache management over a 6 year period.

RESULTS

Sixty-four patients were mostly female (78%) with an average age of 71 years (range 65-94). Representative headache diagnoses were chronic migraine 50%, episodic migraine 12.5%, trigeminal autonomic cephalalgia 9.4%, and occipital neuralgia 7.8%. Average number of headache days/month was 23. Common comorbidities were hypertension 48%, hyperlipidemia 42%, arthritis 27%, depression 47%, and anxiety 33%. Eighty-nine percent were prescribed at least 1 medication fulfilling the Beers criteria. The average number of peripheral nerve blocks per patient was 4. Peripheral nerve blocks were felt to be effective in 73% for all headaches, 81% for chronic migraine, 75% for episodic migraine, 67% for chronic tension type headache, 67% for new daily persistent headache, and 60% for occipital neuralgia. There were no adverse events related to PNBs reported.

CONCLUSIONS

PNBs might be a safe and effective alternative headache management strategy for older adults. Medical and psychiatric comorbidities, medication overuse, and Beers list medication rates were extraordinarily high, giving credence to the use of peripherally administered therapies in the geriatric population that may be better tolerated and safer.

The prevalence of anxiety among older adults in nursing homes and other residential aged care facilities: a systematic review

OBJECTIVES

To synthesize and summarize the studies examining the prevalence rate of anxiety disorders and symptoms in older adults living in residential aged care.

METHODS

Using the PRISMA guidelines, five electronic databases were searched using key terms and subject headings, as well as reference lists of relevant papers. The search was limited to literature published in English. Eligible studies examined the prevalence of anxiety disorders or symptoms in aged care residents aged 50+ years.

RESULTS

A total of 2249 articles were identified, of which 18 studies (with a total of 5927 participants) were included in this review. The rate of overall anxiety disorders ranged from 3.2% to 20%, with the highest quality studies estimating a prevalence rate of 5% to 5.7%. Generalized anxiety disorder and specific phobias were found to be the most common anxiety disorders among aged care residents, while clinically significant anxiety symptoms were found to be more frequent (6.5% to 58.4%) than threshold disorders.

CONCLUSIONS

Anxiety disorders and anxiety symptoms are common in older aged care residents. Given the paucity and overall quality of research examining anxiety within this population and the heterogeneity found in studies, further research is needed to help clarify this issue.

Psychiatric disorders in ageing

The ageing of the population brings particular challenges to psychiatric practice. Although the clinical presentation of common psychiatric disorders such as mood and psychotic disorders is largely similar to those in younger adults, late life presentations tend to be more complex as co-morbidity with dementia and physical illness is common. Suicide tends to increase with age in most countries. In this chapter we argue that the aetiology of disorders may be best understood within a stress vulnerability model in which neurobiological and psychosocial factors interplay. We further present that management strategies need to be comprehensive, incorporating physical, social, pharmacological, and psychological treatments appropriate to each case. We close with a call for the use of specialised multi-disciplinary services to improve the overall quality of care.

Anxiety, anxiety symptoms, and associations among older people with dementia in assisted-living facilities

Anxiety is a major cause for distress among older people with dementia, and it impedes care. In order to develop interventions to treat anxiety and identify who might be most likely to benefit, mental health nurses need to understand what clinical and demographic factors are associated with anxiety in dementia. This cross-sectional study is a detailed assessment of anxiety in people living in assisted-living facilities using the Rating Anxiety in Dementia (RAID) scale and the Clinical Anxiety Scale (CAS). One hundred and forty-eight people, with a mean age of 86.2 years, were recruited from 19 assisted-living facilities in the USA. Prevalence rates for anxiety were 11% and 18%, as measured on the RAID and CAS, respectively. One or more symptoms of anxiety were exhibited for 49% (RAID) and 48% (CAS) of participants. Behavioural symptoms and the presence of depression strongly predicted anxiety, as did staff's reaction to behavioural symptoms and their sense of competence to care. These findings demonstrate that anxiety is prominent enough to warrant further investigation and treatment, and that anxiety in older people with dementia is closely associated with staff skill. This study has also identified areas for mental health nurses to target interventions.

Mental disorders affect older persons in Sweden--a register-based study

OBJECTIVE

The study aimed to estimate the prevalence of mental disorders based on pharmaceutical use among the old (age ≥65) in Sweden for the years 2006-2008.

METHODS

Data on the mental health of older persons were approximated on the basis of recommended prescriptions for pharmaceuticals, gathered from the Swedish Register on Prescribed Pharmaceuticals (SRPP). Each disorder (ICD-10, F20-F42, and F60-F61) was analyzed to identify associated recommended pharmaceuticals. Anatomical Therapeutic Chemical Classification codes were applied. The data covered 188,024 individuals who received 2,013,079 prescriptions for pharmaceuticals for mental disorders during a 3-year period. Persons with pharmaceuticals for dementia disorders were excluded from the calculations of the prevalence of mental disorders.

RESULTS

The prevalence of mental disorders among the old in Sweden, measured on the basis of pharmaceutical use, was 6.6% in 2006, 2007, and 2008, respectively. Men constituted one-third of cases and women two-thirds. Prevalence was lowest in the age group 65-69 and increased subsequently with age.

CONCLUSIONS

This fundamental register-based study included a great number of older persons and shows that mental disorders affect every fifteenth older person in Sweden. The prevalence of mental disorders increases with increasing age. The results highlight the extent of mental disorders among older persons, which is important to know when planning care for these patients. This study, by investigating a large population, provides a solid basis for general planning as well as for future mental disorder research.

Anxiety in dementia: a critical review

Until recently, little attention has been paid to anxiety symptoms in dementia. However, anxiety is common in this population, and associated with poor outcome and quality of life. The current review examines the existing literature around three major themes: the definition of anxiety in dementia, the properties of available instruments for assessment, and the clinical characteristics of anxiety in this population. Defining anxiety in individuals with dementia is complicated by the overlap between symptoms of anxiety, depression and dementia, and by the influence of the source of information. Several instruments are available to assess anxiety in this population, including general neuropsychiatric instruments and two scales designed specifically for this purpose. The reliability of these instruments is acceptable, but their validity has not been sufficiently examined, and they may discriminate poorly between anxiety and depression. Anxiety may be higher in vascular dementia than in Alzheimer's Disease, and it decreases in the severe stages of dementia. It is associated with poor quality of life and behavioral disturbances, even after controlling for depression. Little is known, however, about its social and environmental correlates. Limitations of the existing literature and key directions for future research are discussed.

The prevalence of anxiety in older adults: methodological issues and a review of the literature

BACKGROUND

Despite the relative neglect of anxiety in older adults, the growing literature on its prevalence suggests that anxiety is highly prevalent and associated with considerable distress and morbidity in this age group. This review provides a comprehensive overview of this literature and discusses some unresolved controversies in the field.

METHODS

A systematic search of articles published from 1980-2007 was performed. Articles were included for review if they reported the prevalence of anxiety symptoms, anxiety disorder or specified anxiety disorders in adults aged >60 in either community or clinical settings.

RESULTS

The prevalence of anxiety in community samples ranges from 1.2% to 15%, and in clinical settings from 1% to 28%. The prevalence of anxiety symptoms is much higher, ranging from 15% to 52.3% in community samples, and 15% to 56% in clinical samples. These discrepancies are partly attributable to the conceptual and methodological inconsistencies that characterise this literature. Generalised Anxiety Disorder is the commonest anxiety disorder in older adults.

LIMITATIONS

The methodologies used in the studies are so variable as to make comparisons difficult.

CONCLUSIONS

Although anxiety disorder, particularly Generalised Anxiety Disorder is common, issues in relation to comorbidity and the nature of anxiety in old age remain unresolved. This hampers the design of intervention programmes, and highlights the need for further research with a primary focus on anxiety.

Generalised Anxiety Disorder in Elderly Patients

Generalised anxiety disorder (GAD) is characterised by at least 6 months of excessive uncontrollable worry accompanied by symptoms of motor tension and vigilance and scanning. As with other anxiety disorders, GAD is less prevalent in older adults than younger adults. GAD has a high level of comorbidity with other psychiatric disorders and this has a bearing on estimates of its prevalence. GAD that is comorbid with another psychiatric disorder has a period prevalence of approximately 4% in community-dwelling older people. On the other hand, 'pure' GAD is less common, with a period prevalence of approximately 1%. Pure GAD in late life is a fairly even mix of chronic cases that began earlier in life and cases starting for the first time in later life. The most frequent and consistent finding regarding late-life generalised anxiety is its high level of comorbidity with major depression. There are few longitudinal data pertaining to the temporal association of generalised anxiety and major depression in late life, but the data that do exist suggest that the anxiety is frequently symptomatic of the depression. If generalised anxiety occurs exclusively during episodes of major depression, a separate diagnosis of GAD is not warranted. Cognitive behaviour therapy (CBT) is the most frequently studied psychological treatment for GAD. Although CBT is more effective than a wait-list control condition, it is not more effective than nondirective therapies in late-life GAD. Furthermore, a standard course of CBT appears to be less efficacious for GAD in older adults than younger adults. Further research is needed to develop more efficacious and specific forms of psychotherapy for late-life GAD. The three classes of medications that are most commonly used for GAD are: (i) antidepressants; (ii) benzodiazepines; and (iii) buspirone. Antidepressant medication is the pharmacological treatment of choice for most older adults with generalised anxiety. When generalised anxiety is secondary to an episode of major depression, the selection of an antidepressant is guided by the same principles that apply to treatment of nonanxious depression. Antidepressant medication is also effective for GAD in the absence of an episode of major depression. In this situation, citalopram and venlafaxine have been found to be efficacious in older people. Data from studies of mixed-aged patients suggest that escitalopram, paroxetine and trazodone may also be beneficial in late-life GAD. Despite their widespread use in older persons with anxiety, benzodiazepines have a limited role in the treatment of GAD in the elderly. If a benzodiazepine is initiated, pharmacokinetic considerations favour the use of either lorazepam or oxazepam. Buspirone also has a more limited role than antidepressants in the treatment of late-life GAD.

Epidemiology of late-life mental disorders

This article reviews the prevalence and incidence of mental disorders in older adults. The authors outline the epidemiologic challenges in determining the frequency of mental disorders in late-life and discuss issues that are critical for understanding the prevalence of the disorders and for reviewing the evidence from epidemiologic studies of mental disorders in this population. The authors summarize the epidemiologic data for depression, anxiety, dementia, schizophrenia, and alcoholism. Also included is a discussion of risk factors and outcomes of these disorders and a discussion of the implications of these epidemiologic findings for geriatric medicine.

Diagnosis and Management of Panic Disorder in Older Patients

Panic disorder occurs less frequently in the elderly than in younger adults and rarely starts for the first time in old age. Panic attacks that begin in late life should prompt the clinician to conduct a careful search for a depressive disorder, physical illness or drugs that could be contributing to their presence. When panic attacks do occur in the elderly, the symptoms are qualitatively similar to those experienced by younger people. The elderly, however, may have fewer and less severe symptoms and exhibit less avoidant behaviour. As panic disorder is typically a chronic or recurrent condition, its management requires a long-term approach. With the exception of one descriptive pilot study, there have been no randomised controlled trials of the treatment of panic disorder in later life. Therefore, recommendations regarding the management of this disorder in the elderly must be extrapolated from research pertaining to younger patients. Selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, monoamine oxidase inhibitors, benzodiazepines and cognitive behavioural therapy are efficacious treatments for panic disorder. There are no consistent differences in efficacy between classes of medications or between pharmacotherapy and cognitive behavioural therapy. Furthermore, there are no reliable predictors of response to one type of treatment compared with another. Treatment selection, therefore, depends on an individual assessment of the risks and benefits of each type of treatment (taking into account comorbid psychiatric and physical conditions), patient preference, cost and the availability of therapists skilled in cognitive behavioural techniques. As a general rule, antidepressant medication is preferable to a benzodiazepine as a first-line treatment for panic disorder in the elderly, especially given the high level of comorbidity between panic disorder and depressive disorders. Of the antidepressants, an SSRI is recommended as the initial choice of treatment in older patients. Anxious patients frequently misattribute somatic symptoms of anxiety to adverse effects of medication. Adherence with treatment, therefore, can be enhanced by starting antidepressant medication at a low dosage so as to avoid initial exacerbation of anxiety (but then gradually increasing the dosage to the therapeutic range), frequent follow-up during the first few weeks of treatment, discussion about potential adverse effects and addressing any other concerns the patient may have about taking medication. Given the delayed onset of action of antidepressant medication, the short-term use of adjunctive lorazepam in the first few weeks of treatment may be helpful in selected patients.

Anxiety disorders in older adults

In the population of older adults, anxiety disorders are underdiagnosed and undertreated. Epidemiologic studies have generally found that the prevalence of anxiety disorders declines with age. Recognition of anxiety disorders in older adults is, however, complicated by several age-related factors including the presence of depression, cognitive impairment, and physical illness. A variety of medications have been used to treat anxiety disorders across the life span; however, few studies have evaluated their use specifically in older adults. Choice of medication requires consideration of the effects of aging on safety, tolerability, and adherence. Available data suggest that cognitive and behavioral treatments may be effective for anxiety disorders in older adults. Appropriate medical evaluation and psychosocial interventions are recommended prior to initiating pharmacotherapy. When pharmacologic treatment is warranted, antidepressant medications at low doses may be useful for late-life anxiety disorders; other agents may be considered for augmentation or second-line use in certain types of patients.

Anxiety disorders in the elderly

Although the epidemiology, neurobiology, and treatment of anxiety disorders have received considerable attention in the child and adult literature, they have not received the same consideration in the geriatric population. This disparity is remarkable given the prevalence and associated costs of these disorders that can persist into late life. Further, although a considerable amount is known about these disorders in younger age groups, it is unclear whether the phenomenology of anxiety evolves over the course of the aging process. Thus, conclusions drawn based on younger populations of anxious adults may not hold true for older cohorts. This article reviews issues of epidemiology, phenomenology, neurobiology, and medical comorbidity, as well as pharmacologic and psychotherapeutic treatments in older adults.

Anxiety disorders in late life

OBJECTIVE

To review the epidemiology, clinical characteristics, and treatment of anxiety disorders in late life.

QUALITY OF EVIDENCE

Epidemiologic and comorbidity data are derived from well designed random-sample community surveys. There are virtually no controlled data specific to treatment of anxiety in the elderly. Guidelines for treating anxiety disorders in late life, therefore, must be extrapolated from results of randomized controlled trials conducted in younger patients.

MAIN MESSAGE

Generalized anxiety disorder and agoraphobia account for most cases of anxiety disorder in late life. Late-onset generalized anxiety is usually associated with depressive illness and, in this situation, the primary pharmacologic treatment is antidepressant medication. Most elderly people with agoraphobia do not give a history of panic attacks; exposure therapy is the preferred treatment for agoraphobia without panic.

CONCLUSIONS

Physicians need to make more use of antidepressant medication and behavioural therapy and less use of benzodiazepines in treating anxiety disorders in late life.

The relationship between anxiety disorders and age

OBJECTIVES

To review the major community-based epidemiological studies that have reported data on anxiety disorders in individuals aged 65 and over and to examine age-related changes in their prevalence and incidence.

DATA SOURCES AND STUDY SELECTION

All English language entries relating to anxiety in the BIDS, EMBASE, Medline and PsychLit computerized databases, together with a search of relevant citations.

DATA SYNTHESIS

The prevalence of phobic disorders in the population aged 65 or over lies between 0.7% and 12% over a 1-6-month period. As the rates for social phobia, 1%, and simple phobia, 4%, are fairly consistent, much of this variation is due to agoraphobia, whose prevalence lies between 1.4% and 7.9%. The prevalence of obsessive-compulsive disorder is 0.1-0.8%, panic disorder 0.1% and generalized anxiety 4%. Women do have a higher prevalence of anxiety disorders than men but this difference diminishes with increasing age, as does the apparent prevalence of all anxiety disorders apart from generalized anxiety, measured without hierarchical rules, which appears to be maintained or increase. The relative importance of various explanations for this apparent reduction is discussed, including the three that are of greatest public health and clinical importance: cohort effects, anxiety-related mortality and comorbidity between anxiety and cognitive impairment. A tri-dimensional approach (psychic, somatic and behavioural) to anxiety measurement is advocated in order to facilitate future studies of age-related changes which may lead to a reappraisal of the status of generalized anxiety as a 'residual category'.