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

2. Disclosure None for this presentation.

3. How Common is Clinically Significant Anxiety in Older ReferenceInstrumentPrevalence Beekman et al. 1998 DIS/DSM-III10.2% Regier et al. 1988 DIS/DSM-III5.5% Bland et al. 1988 DIS/DSM-III3.5% Weissman et al. 1985 DIS/DSM-III4.6% Saunders et al. 1993 GMS-AGECAT2.5%

4. 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)

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

6. 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

7. 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)

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

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

10. 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

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

12. Exposure  (Flooding)  Systematic desensitization  Response prevention

13. 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

14. 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)

15. 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