Anxiety Disorders in Older People George T. Grossberg, MD Samuel W. Fordyce Professor Director, Geriatric Psychiatry Saint Louis University School of Medicine

Disclosure None for this presentation.

How Common is Clinically Significant Anxiety in Older ReferenceInstrumentPrevalence Beekman et al DIS/DSM-III10.2% Regier et al DIS/DSM-III5.5% Bland et al DIS/DSM-III3.5% Weissman et al DIS/DSM-III4.6% Saunders et al GMS-AGECAT2.5%

Different Types of Anxiety Disorder  Generalized Anxiety Disorder (common)  Phobic Disorders ( common) -Agoraphobia -social phobia -Specific phobia  Panic disorder (rare)  Post-traumatic Stress Disorder (uncommon)  Obsessive Compulsive Disorder (rare)  Anxiety Disorder due to a General Medical condition (common)

Putative Causes of Anxiety in Older People  Genetic vulnerability  Structural brain changes  Medical illness  Personality traits  Adverse life events

Medical Conditions Commonly Associated with Anxiety  Hyperthyroidism; diabetes mellitus  Ischemic heart disease  Chronic obstructive pulmonary disease  Gastrointestinal disease  Parkinson’s disease  Alzheimer’s disease  Stroke

Relationship between Medical Disorders and Anxiety  Co-occurrence of two common disorders  Somatic symptoms of anxiety (e.g. dyspnea)  Anxiety as a psychological reaction to major medical illness (e.g., MI)  Direct effect of illness on the brain (e.g. CVA, AD)  Medical illness causing anxiety symptoms (e.g., hyperthyroidism)  Anxiety as a side effect of medication (e.g. beta agonists; anti-parkinsonian drugs)

Scales to Assess Anxiety More Work Needed  Worry Scale  State-Trait Anxiety Inventory  Penn State Worry Questionnaire  Beck Anxiety Inventory  Fear Questionnaire  Padua Inventory

Treatment of Anxiety Disorders in Older People  Identify & manage comorbid medical problems  Identify & manage cormorbid psychiatric problems (esp. depression, psychosis & dementia)  Non-pharmacological  Pharmacological

Non-Pharmacological  Psychoeducation: -Explanation of the nature of anxiety & its symptoms  CBT: -Relaxation training -Self-talk & imagery -Cognitive restructuring -Social Skills training -Distraction techniques -Exposure

Relaxation Training  Progressive muscular relaxation  Controlled breathing  Visual imagery

Exposure  (Flooding)  Systematic desensitization  Response prevention

Pharmacological  Benzodiazepines -Toxicity (amnesia & confusion; ataxia & unsteadiness)  Buspirone -Toxicology good; efficacy & speed of onset poor  Antidepressants -TCAs -SSRIs -SNRI  Other drugs -Beta Blockers (often not ideal for older patients) -Cholinesterase inhibitors

Use of Newer Antidepressants  Initial increase in anxiety and insomnia in some patients -start with very low dose in older patients (e.g., 10 mg citalopream or 37.5 mg venlafaxine) -add low-dose short-acting benzodiazepine for first two weeks (e.g., oxazepam, lorazepam)

Conclusion  Increased realization of overlap between depression & anxiety in older people  Convergence of treatment approaches to depression & anxiety in older people  Combination treatment with psychological interventions and antidepressant medication usually works best