Anxiety Disorders in the Elderly

Anxiety Disorders in the Elderly

Jason Jalil, MD

Assistant Clinical Professor David Geffen School of Medicine

Department of Psychiatry and Biobehavioral Sciences

Outline

• Overview of anxiety and anxiety disorders

• Generalized anxiety disorder

• The fear of falling

• Social phobia/social anxiety disorder

• Hoarding disorder

• Dementia and anxiety

• Pharmacotherapy

• Disclaimer: we are living in stressful times

• Anxiety as a symptom is NORMAL

• It is a psychological, physiological and behavioral state

• It serves to prepare oneself for an adverse or unexpected situation

• Anxiety becomes pathological when it becomes excessive, interferes with functioning and focuses on an unknown or unrealistic threat

• Overall, the lifetime prevalence of an anxiety disorder is about 25%

• The incidence of anxiety disorders in older adults is lower than younger counterparts

• Except for Generalized Anxiety Disorder (GAD), where the rate is relatively unchanged (11.6%)

• GAD is likely the most common anxiety disorder among the older adult population

• Data is conflicting (and likely underreported) due to numerous issues with diagnosing a formal anxiety disorder in this particular population

Confounding Factors and Challenges in Diagnosis

• Impaired communication skills in the elderly

• Patient presentation with multiple somatic complaints

• Comorbid medical issues (e.g. heart disease)

• Misperceptions of “normal aging”

• Perceived stigma of mental illness

• Limited access to psychiatric care

• Co-occurring cognitive disorders

• Misinterpretation of “real” versus imagined or exaggerated fear

• The prevalence of late-life anxiety disorders is even higher among older adults who are:

• Homebound

• Nursing home/facility residents

• Also afflicted with chronic medical illness

• Risks of untreated or undertreated anxiety disorders in the elderly:

• Decreased physical activity and functional status

• Poorer self-perceptions of health

• Decreased life satisfaction

• Increased loneliness/isolation

• Poorer quality of life

• More adverse health outcomes, including death

• Increased healthcare costs/systemic burden

• One of the leading causes of disability in the United States

• Problem: Some of these symptoms overlap with signs of normal aging, medication AE and/or co-morbid medical conditions

• Problem: Some of the ”typical” physical symptoms of anxiety may be masked or lessened in older adults who may not (or cannot) mount a strong autonomic response

Rule-Out to Work-Up

• Levodopa

• Amantadine

• Bromocriptine

• MAO inhibitors

• Theophylline

• Interferon

• Thyroid hormones

• Caffeine

• Amphetamines

• Methylphenidate

• Modafinil/Armodafinil

• Bupropion

• Sympathomimetics

Common medications that may trigger anxiety:

Rule-Out to Work-Up

• Neurologic

• Stroke

• Parkinsonism

• Epilepsy

• Multiple Sclerosis

• Malignancy

• Cardiac/CVS

• Angina

• Mitral valve prolapse

• Cardiac arrythmia

• Pulmonary

• Asthma

• Gastrointestinal

• Irritable bowel syndrome

• Hepatic failure

• Metabolic/Endocrine

• Hypoglycemia

• Hypo- or hypercalcemia

• Hyperthyroidism

• Pheochromocytoma

• Hyperparathyroidism

• Carcinoid syndrome

• Uremia

• Thiamine deficiency

• Folate deficiency

• B6 (pyridoxine) deficiency

• B12 deficiency

• Malignancy

• Paraneoplastic syndrome

• Toxidromes

Generalized Anxiety Disorder

• Most common anxiety disorder in older adults

• Bimodal incidence: early onset (teens/20s) with late-life exacerbation versus late-onset (after the age of 50 YO)

• Late-onset GAD is usually associated with certain demographic, clinical, and environmental risk factors

• Female gender

• Adverse life events

• Chronic physical and mental health disorders

• Poverty

• Parental loss or separation

• Low affective support during childhood

Lenze, 2010; Zhang et al., 2015

Generalized Anxiety Disorder

• Excessive anxiety, apprehension and worry about a number of events or activities for greater than 6 months

• Difficulty controlling the worry

• Associated physical (restlessness, easily fatigued, muscle tension, sleep disturbances), cognitive (difficulty concentrating) and/or emotional (irritability) symptoms

Generalized Anxiety Disorder

• Worry content changes and adapts with age—often problems that arise in later stages of life:

• Health concerns

• Welfare or loss of loved ones

• Finances and health care costs

• Life transitions

• Retirement

• Caregiver responsibility

• End of life planning

Lenze, 2010

Generalized Anxiety Disorder

Treatment:

• Limited RCT

• Data: SSRI + CBT better efficacy

• Psychopharmacologic

• First line: SSRI, SNRI

• Second line: addition of adjuvant treatment (buspirone, SGA, benzodiazepines, gaba)

• Buspar data is scant; effective and safe (Mokhber et al., 2010)

• Pregabalin tolerated and effective (Montgomery et al., 2008)

• Quetiapine (Kreys et al, 2010)

• Psychotherapy

• CBT, CBT, CBT

• Few caveats:

• Adaptations required for efficacy

• May require increased repetition

• May required increased time

• Consider combining with cognitive rehab

Lenze et al., 2009

• Mind-body interventions

• Mindfulness-based stress reduction (MBSR)

• Acceptance and Commitment Therapy (ACT)

• Complementary and Alternative Treatments

• Silexan (lavender oil extract)

• Acupuncture

• Aromatherapy and massage

Rating Scales

• Geriatric Anxiety Inventory (GAI)

• Pachana et al., 2007: 20-item self-report (“Agree”/“Disagree”)

• Available in over 20 language translations

• Geriatric Anxiety Scale (GAS)

• Segal et al., 2010: 30-item self-report (4-point Likert scale)

• Scoring provides a total score and 3 subscale scores (somatic symptoms, cognitive symptoms, and affective symptoms

• Generalized Anxiety Disorder scale (GAD-7)

• Spitzer et al., 2006: 7-item self-report (4-point Likert scale)

• Suggested to consider lower cut-off scores for older adults

Specific Phobia: Fear of Falling

Also called the post-fall anxiety syndrome

• In general, falls in older persons occur commonly and are major factors threatening the independence of older individuals

• Additionally: a significant source of morbidity and mortality

• Falls are the leading cause of injury, both fatal and nonfatal, among older adults in the United States

Moreland et al., 2020

Specific Phobia: Fear of Falling

• Fear of falling is a specific phobia

• An excessive, unreasonable and persistent fear of an object or situation (i.e.

falling)

• Unbridled fear relative to the objective fall risk

• Lack of insight into excessiveness of fear

• Prevalence in older adults 12-65%

• 92% prevalence in those with a history of falls

• Prevalence in women > men

Evitt and Quigley, 2004

Specific Phobia: Fear of Falling

• Risk factors:

• Living alone

• Cognitive impairment

• Co-existing depression

• Pre-existing morbidities/health issues

• Balance and mobility impairments

• A history of falls, especially traumatic or injurious falls

Evitt and Quigley, 2004

Specific Phobia: Fear of Falling

• Fear of falls will result in:

• A higher risk of falling

• Maladaptive gait changes

• Avoidance of multiple situations and activities

• Withdrawal from social and physical activities

• An increased risk of institutionalization

• Moderate to severe activity restriction

• Increased mortality

Tinetti et al., 1994

Specific Phobia: Fear of Falling

Treatment:

• Limited evidence-based treatments/interventions

• Address underlying modifiable risk factors

• Reduce medications that increase fall risk

• Balance training to prevent falls and increase self-efficacy

• Exercise to reduce fall risk, including balance and functional exercises such as Tai Chi and the Otago Exercise Program (OEP)

• Exposure-based CBT

Social Phobia/Social Anxiety Disorder

• Overwhelmingly feeling of anxiety and self-consciousness in everyday social situations

• Chronic fear of being judged by others and of doing something that will cause embarrassment

• Issues with shame in the older adult:

• Cognition, remembering names

• Appearance due to aging or illness

• Functional impairments, loss of independence

• Outward manifestations of anxiety

Social Phobia/Social Anxiety Disorder

• Anxiety not just in social circumstance, but also beforehand

• Physical symptoms:

• Blushing

• Sweating

• Trembling

• Nausea

• Dry mouth

• Palpitations

• Difficulty speaking

• Incontinence

Social Phobia/Social Anxiety Disorder

• Onset typically as a younger adult, with continuation into older adulthood

• Lifetime prevalence of 6.6%

• Usually underestimated in older adults

• Both from a statistical and symptomatologic standpoint

Social Phobia/Social Anxiety Disorder

Treatment:

• Pharmacotherapy: SSRI, SNRI

• Adjuvant treatment: gabapentin and pregabalin with modest efficacy

• Mirtazapine: limited efficacy in geriatric social anxiety disorders (Schutters et al., 2010)

• Therapy: CBT

• Combined CBT + pharmacotherapy

Hoarding Disorder

• Though not a common disorder, the prevalence of detection of problematic cases tends to be higher in older adults

• Previously classified under OCD; stand alone diagnosis in DSM-5

• Excessive acquisition of and persistent difficulty in discarding or parting with possessions (regardless of their actual value), e.g.:

• Newspapers

• Clothing

• Food items

• Perceived utility or aesthetic value to the hoarded items

Mataix-Cols et al., 2010

Hoarding Disorder

• Hoarding causes significant distress and impairment in social,

occupational, and/or other important areas of functioning (including maintaining a safe environment for self and others)

Hoarding Disorder

• Prospect of discarding these possessions usually causes substantial distress

• This will lead to an accumulation of items— “clutter”

• Unsafe and unsanitary living environments

• Inadequate access to food, running water, electricity and/or ventilation

• Fire hazards

• Fall risks

• Vermin infestation

• Structure damage

• Hazardous material exposure, including chemicals and bodily fluids

challengingdisorganization.org, 2021

Hoarding Disorder

• Collaborative intervention

• Service providers, mental health professionals and professional organizers

• Treatment

• CBT

• Cognitive remediation

• Improved cognitive function through repeated task practice

• Limited data for pharmacotherapy (SRI?)

Frost and Hartl, 1996

Dementia and Anxiety

• Two approaches:

• Cognitive impairment secondary to anxiety disorder

• Anxiety symptoms secondary to a cognitive disorder

Dementia and Anxiety

• Cognitive impairment secondary to anxiety disorder

• Consists mostly of memory and executive function impairment

• Anxiety may present with cognitive symptoms:

• Difficulties attending and concentrating

• Memory impairment, short-term memory, retrieval/working memory

• Word-finding difficulties

• Difficulty staying on task

• Reduced problem-solving ability

• Cognitive symptoms reverse with treatment or abatement of anxiety symptoms

Lenze et al., 2011

Dementia and Anxiety

• Anxiety symptoms secondary to a cognitive disorder

• Insight into cognitive symptoms and associated difficulties can be anxiety-provoking

• New onset anxiety symptoms/disorders in an older adult may be a prodromal state for a neurocognitive disorder

• New onset anxiety symptoms were associated with increased risk of conversion from MCI to dementia (Rosenberg et al., 2013)

• “Anxiety” as a behavioral and psychological symptoms of dementia (BPSD) (e.g.

dementia with behavioral disturbances)

• Anxious distress

• Agitation

• Insomnia

• Pacing

• Restlessness

• Hoarding

Pharmacotherapy

• The evidence base for pharmacotherapy in older adults is limited and consists mostly of several small clinical trials, many dated and in mixed populations

• General principles

• “Start low, go slow, but go!”

• Monotherapy is preferred

• Reduced drug-drug interactions

• Minimized drug adverse effects

• Considerations for polypharmacy

• Treatment refractoriness, partial response

• Symptom severity

• Comorbid symptoms

Selective Serotonin Reuptake Inhibitors (SSRIs)

Citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline

• Considered first-line for treatment of anxiety disorders in older adults

• Better tolerability, ease of use, and general safety (Sonnenberg CM, 2008)

• Special considerations

• Citalopram: maximum recommended dose of 20 mg per day (for patients 60+ years) due to increasing the risk of QT prolongation and Torsade de Pointes (FDA.gov, 2021)

• Paroxetine: Beers Criteria and anticholinergic properties

• Fluoxetine: long half-life and several drug-drug interactions

• Potent CYP2D6 and CYP2C19 inhibitor

• Moderate CYP2B6 and CYP2C9 inhibitor

Stahl, 2018; Micromedex Drug Reference, 2021

Selective Serotonin Reuptake Inhibitors (SSRIs)

• Notable side effects

• Risk of Parkinsonism (rare)

• Akathisia

• Bradycardia

• Hyponatremia

• Increased risk of serotonin syndrome in older adults

• May displace highly protein bound drugs such as warfarin, which increases bleeding risk (apart from risk due to inhibition of platelet aggregation)

• Clinical pearls

• Fluoxetine, escitalopram, citalopram and paroxetine are available in liquid form

• Sertraline has the best cardiovascular safety of any antidepressant

• Proven safe and effective for patients with recent MI or angina “SADHART” study (Glassman et al., 2002)

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Duloxetine, desvenlafaxine, levomilnacipran, venlafaxine

• Used in patients with comorbid chronic pain, especially duloxetine

• Can be effective for patients with vasomotor symptoms

• Consider in patients who do not respond or remit on treatment with SSRI

• Notable side effects

• Diastolic hypertension (dose-dependent, especially with venlafaxine)

• Insomnia

• Hyponatremia (though lower risk than SSRI)

• Urinary hesitancy (men > women)

• Increased risk of serotonin syndrome in older adults

Stahl, 2018; Micromedex Drug Reference, 2021

Atypical Antidepressants

Mirtazapine

• Serotonin norepinephrine receptor antagonist and alpha-2 antagonist

• Useful in cases where insomnia, agitation or restlessness, and anorexia or weight loss are a concern

• May be helpful in patients with Parkinson disease

• May minimize nausea from chemotherapy or nausea, diarrhea and GI adverse effects from SNRIs or SSRIs

• With caution for serotonin toxicity when used concomitantly

• Higher doses are more noradrenergic

• Makes higher doses less sedating

• Clinical pearl: available as an oral dissolving sol-tab

Stahl, 2018

Tricyclic and Tetracyclic Antidepressants

Amitriptyline, doxepin, imipramine, nortriptyline

• Usually third-line agents due to numerous side effects

• Associated with a higher withdrawal rate due to side effect experience (Mottram P, 2006)

• Use with caution

• Cardiac arrhythmias and other conduction abnormalities

• Use with caution following recent MI

• Diseased heart more prone to cardiac toxicity (including heart failure, QTc prolongation, arrhythmia and death)

• In this population, may opt for SSRI instead (i.e., sertraline)

• Narrow angle glaucoma

• Urinary retention

• BPH

• Orthostatic hypotension

• Constipation

• Delirium

Stahl, 2018; Micromedex Drug Reference, 2021

Tricyclic and Tetracyclic Antidepressants

• Other considerations

• Neuropathic pain/chronic pain

• Sleep maintenance insomnia (low-dose doxepin)

• Primary insomnia (amitriptyline)

• Monitoring

• Baseline EKG recommended for patients >50 years of age

• Plasma drug levels (nortriptyline)

• Risk of precipitating mania greater in older adults (Young et al., 2003)

• Clinical pearls

• Doxepin, nortriptyline available in liquid form

• Doxepin available in topical formulation

Adjuvant Treatments

Benzodiazepines

• Efficacious in treatment of GAD and other anxiety disorders

• Compared with younger subjects (<50 years old), older adults more often received

benzodiazepines in the absence of an antidepressant (38–43% compared to 28–32%) (Uchida et al., 2009)

• Mostly rapid acting

• Concerns about risks of dependence and tolerance, plus other notable side effects

• Sedation

• Dizziness and falls

• Psychomotor impairment

• Cognitive impairment

• Respiratory depression

• Urinary incontinence

• Paradoxical response

• Mortality

Adjuvant Treatments

Buspirone (BuSpar)

• Serotonin 1A partial agonist

• Often used as an augmenting agent to SSRIs or SNRIs

• Generally takes 2-4 weeks to achieve efficacy

• May be undesirable in some anxiety disorders (e.g. panic disorder)

• Notable AE: dizziness, headache sedation, nausea

• Full effect usually requires dosing 2-3 times a day

• Advantages: lack of dependence/abuse and withdrawal

• Clinical pearl: may reduce SSRI-induced sexual dysfunction

Stahl, 2018

Adjuvant Treatments

Gabapentin

• Off-label use for anxiety disorders

• Notable AE: sedation (dose dependent), fatigue, dizziness, ataxia (dose dependent), GI distress

• Renal dosing

• Clinical pearl: available in liquid form Pregabalin

• Off-label use for GAD, panic disorder and social anxiety disorder

• Effective for older adults with GAD (Montgomery et al., 2009)

• Notable AE: sedation dizziness, euphoria, GI distress

• Renal dosing

Stahl, 2018

Adjuvant Treatments

Second Generation Antipsychotics

• e.g. olanzapine, quetiapine, risperidone

• Often used, but generally not recommended due to abundance of side effects (sedation, weight gain/metabolic AE, tardive dyskinesia, orthostatic hypotension, QTc prolongation)

• Increased safety concerns with comorbid dementia

• Use with caution

Complementary and Alternative Medicines (CAM)

• Large shift towards holistic and complementary approaches, both by providers and patients

• Desire to limit side effects

• Rising healthcare and medication costs

• General dissatisfaction with current treatment options

• An abundance of clinically irrelevant data: clinical trials have not shown to be clearly effective or ineffective

• Mostly small sample sizes

• Methodologic limitations

• Further research is warranted

Complementary and Alternative Medicines (CAM)

• Silexan (Lavandula oil)

• Oral formulation

• Meta analysis showed it to be superior to paroxetine (Yap et al., 2019)

• AE: nausea, belching, diarrhea

• Kava-Kava (Piper methysticum)

• Mechanism of Action—potential modulation of GABA and inhibition of noradrenaline and dopamine reuptake.

• Shown to reduce anxiety (Lakhan and Vieira, 2010)

• AE: headaches, sedation, sleepiness, hepatotoxicity

Complementary and Alternative Medicines (CAM)

• Chamomile—mixed results

• St. John’s wort—no evidence of efficacy in anxiety disorders (Lakhan and Vieira, 2010)

• Saffron–small studies showed a reduction in depressive and anxious symptoms in MDD with anxious distress (Ghajar et al., 2017)

• Valerian root—small studies, no effect

• Passion flower—mixed results in several small studies (Lakhan and Vieira, 2010)

Conclusions/In Closing

• Anxious symptoms are not anxiety disorder

• Anxiety disorders in older adults are less prevalent than the general adult population, but still likely underreported and under diagnosed

• GAD is most prevalent

• Specific phobia: the fear of falling is probably more unique to this population

• Anxiety disorders in the elderly are an underestimated cause of distress, disability, and mortality risk

• Treatment is variable: match the patient

• Pharmacotherapy, psychotherapy, behavioral interventions, lifestyle changes, complementary and alternative medicines

• SSRIs continue to remain the first-line pharmacologic options

• Room for adjuvant treatment options, including complementary strategies