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    Anxiety in older adults

    Assessment and management of three common presentations


    Anxiety, a normal adaptive emotion that helps one anticipate and prepare for noxious events, can be considered pathologic when it becomes unjustifiably excessive and maladaptive. Such morbid or clinically significant anxiety can range from excessive worry about mundane concerns to intense episodes of fear (panic attacks) that occur for no apparent reason. Clinically significant anxiety is usually manifested by a variety of symptoms, including:

    • cognitive (eg, nervousness, worry, apprehension, fearfulness, irritability)
    • behavioral (eg, hyperkinesis, pressured speech, exaggerated startle response)
    • and physical (eg, muscle tension, chest tightness, palpitations, hyperventilation, parasthesias, sweating, urinary frequency).

    Mixed anxiety-depression Clinicians working with older patients have long observed the frequent and significant overlap of symptoms of anxiety and depression in this population.3 In older patients, anxiety disorders are commonly accompanied by depression, and vice versa. Further, since some symptoms are common to both of these disorders (eg, irritability, sleep and appetite disturbance, difficulty concentrating, poor memory), it may be difficult to distinguish between anxiety and depression. In instances where the clinical picture consists of relatively "pure" anxiety or depression, it is easier to make such a distinction. Predominantly anxious patients are typically more activated, restless, tachycardic, and sweaty, whereas predominantly depressed patients complain of low energy, are slower moving, and appear to lack motivation.


    Table. Pharmacologic strategies for common causes of anxiety in late-life
    Nevertheless, such distinctions are mostly academic because the same classes of medications are used to manage both disorders. Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) are first-line treatments and are effective for most types of anxiety and depression as well as mixed anxiety-depression.4,5 Because antidepressants typically take 2 to 4 weeks to demonstrate their treatment effect, short-term use (2 to 4 weeks) of a short half-life benzodiazepine (eg, lorazepam, 0.25 to 1.0 mg bid to tid; oxazepam, 10 to 15 mg tid) in conjunction with an SSRI or SNRI may be warranted if immediate relief is needed for severe symptoms of anxiety.

    Anxiety associated with illness or medications Anxiety associated with medical conditions or medications is one of the most common presentations of anxiety in late-life. Typically, patients present with a variety of cognitive, behavioral, and physical symptoms of anxiety that range from worry about health and finances to full-blown panic attacks. Anxiety associated with medical conditions can be the result of several factors. First, being the most common psychiatric conditions, anxiety symptoms and syndromes may present as coincidental comorbid conditions in conjunction with commonly occurring medical illnesses such as cardiac, respiratory, and endocrine disorders. In such cases, a long-standing history of an anxiety disorder is typically forthcoming. Second, anxiety can manifest in response to a physical stressor, with a temporal association with the onset of a particular medical disorder. Third, anxiety can be a manifestation of physiologic changes that result from a medical illness (eg, Parkinson's disease) or a medication (eg, theophylline). Among the more common medical disorders that produce symptoms of anxiety are:

    • endocrine conditions (eg, hyper- and hypothyroidism, hypoglycemia)
    • cardiovascular conditions (eg, congestive heart failure, pulmonary embolism, angina, arrhythmias)
    • pulmonary conditions (eg, chronic obstructive pulmonary disease, pneumonia)
    • neurologic conditions (eg, Parkinson's disease, stroke).

    Among the more common substances/medications that produce symptoms of anxiety in older adults are:

    • alcohol (intoxication or withdrawal)
    • stimulants (eg, caffeine, sympathomimetics such as ephedrine or pseudoephedrine in over-the-counter [OTC] medications, theophylline, OTC interactions with prescription medications)
    • steroids
    • thyroid preparations
    • anticholinergic medications
    • antidepressants (ie, for the first 2 to 3 weeks of treatment, which can be managed with the addition of a benzodiazepine for that duration).

    Anxiety/agitation associated with dementia Symptoms of anxiety and agitation commonly accompany dementia. As opposed to subjective apprehension, which occurs with anxiety, agitation is typically expressed as motor restlessness and inappropriate behavior. Anxiety and agitation frequently coexist in the same patient. Early identification of triggers, including environmental stimuli, medication side effects, and the inability to communicate internal needs, can lead to effective treatment of anxiety and agitation and can provide relief for already overburdened caregivers. As is the case with depression, anxiety typically presents in mild-to-moderate cases of dementia, with agitation being more common in moderate-to-severe cases.

    Traditionally, high potency neuroleptics such as haloperidol and fluphenazine have been used with modest efficacy in treating anxiety and agitation associated with dementia. Nevertheless, these drugs can cause acute extrapyramidal reactions or late-developing adverse effects such as tardive dyskinesia, consequently, their use is increasingly limited to acute situations and for brief durations. Newer, atypical antipsychotics, such as risperidone, 0.5 mg bid; olanzapine, 2.5 mg/d; and quetiapine, 100 mg bid, have a lower incidence of treatment-related adverse effects and are now considered the first-line treatments for anxiety and agitation. Short-term judicious use of benzodiazepines can also be beneficial as described previously. Finally, the newer anticonvulsants gabapentin, 100 to 300 mg tid, and lamotrigine, 25 to 100 mg bid, can be useful for treatment-resistant cases.

    Anxiety, a normal adaptive emotion that helps one anticipate and prepare for noxious events, can be considered pathologic when it becomes unjustifiably excessive and maladaptive. Such morbid or clinically significant anxiety can range from excessive worry about mundane concerns to intense episodes of fear (panic attacks) that occur for no apparent reason. Clinically significant anxiety is usually manifested by a variety of symptoms, including:

    • cognitive (eg, nervousness, worry, apprehension, fearfulness, irritability)
    • behavioral (eg, hyperkinesis, pressured speech, exaggerated startle response)
    • and physical (eg, muscle tension, chest tightness, palpitations, hyperventilation, parasthesias, sweating, urinary frequency).

    Mixed anxiety-depression Clinicians working with older patients have long observed the frequent and significant overlap of symptoms of anxiety and depression in this population.3 In older patients, anxiety disorders are commonly accompanied by depression, and vice versa. Further, since some symptoms are common to both of these disorders (eg, irritability, sleep and appetite disturbance, difficulty concentrating, poor memory), it may be difficult to distinguish between anxiety and depression. In instances where the clinical picture consists of relatively "pure" anxiety or depression, it is easier to make such a distinction. Predominantly anxious patients are typically more activated, restless, tachycardic, and sweaty, whereas predominantly depressed patients complain of low energy, are slower moving, and appear to lack motivation.


    Table. Pharmacologic strategies for common causes of anxiety in late-life
    Nevertheless, such distinctions are mostly academic because the same classes of medications are used to manage both disorders. Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) are first-line treatments and are effective for most types of anxiety and depression as well as mixed anxiety-depression.4,5 Because antidepressants typically take 2 to 4 weeks to demonstrate their treatment effect, short-term use (2 to 4 weeks) of a short half-life benzodiazepine (eg, lorazepam, 0.25 to 1.0 mg bid to tid; oxazepam, 10 to 15 mg tid) in conjunction with an SSRI or SNRI may be warranted if immediate relief is needed for severe symptoms of anxiety.

    Anxiety associated with illness or medications Anxiety associated with medical conditions or medications is one of the most common presentations of anxiety in late-life. Typically, patients present with a variety of cognitive, behavioral, and physical symptoms of anxiety that range from worry about health and finances to full-blown panic attacks. Anxiety associated with medical conditions can be the result of several factors. First, being the most common psychiatric conditions, anxiety symptoms and syndromes may present as coincidental comorbid conditions in conjunction with commonly occurring medical illnesses such as cardiac, respiratory, and endocrine disorders. In such cases, a long-standing history of an anxiety disorder is typically forthcoming. Second, anxiety can manifest in response to a physical stressor, with a temporal association with the onset of a particular medical disorder. Third, anxiety can be a manifestation of physiologic changes that result from a medical illness (eg, Parkinson's disease) or a medication (eg, theophylline). Among the more common medical disorders that produce symptoms of anxiety are:

    • endocrine conditions (eg, hyper- and hypothyroidism, hypoglycemia)
    • cardiovascular conditions (eg, congestive heart failure, pulmonary embolism, angina, arrhythmias)
    • pulmonary conditions (eg, chronic obstructive pulmonary disease, pneumonia)
    • neurologic conditions (eg, Parkinson's disease, stroke).

    Among the more common substances/medications that produce symptoms of anxiety in older adults are:

    • alcohol (intoxication or withdrawal)
    • stimulants (eg, caffeine, sympathomimetics such as ephedrine or pseudoephedrine in over-the-counter [OTC] medications, theophylline, OTC interactions with prescription medications)
    • steroids
    • thyroid preparations
    • anticholinergic medications
    • antidepressants (ie, for the first 2 to 3 weeks of treatment, which can be managed with the addition of a benzodiazepine for that duration).

    Anxiety/agitation associated with dementia Symptoms of anxiety and agitation commonly accompany dementia. As opposed to subjective apprehension, which occurs with anxiety, agitation is typically expressed as motor restlessness and inappropriate behavior. Anxiety and agitation frequently coexist in the same patient. Early identification of triggers, including environmental stimuli, medication side effects, and the inability to communicate internal needs, can lead to effective treatment of anxiety and agitation and can provide relief for already overburdened caregivers. As is the case with depression, anxiety typically presents in mild-to-moderate cases of dementia, with agitation being more common in moderate-to-severe cases.

    Traditionally, high potency neuroleptics such as haloperidol and fluphenazine have been used with modest efficacy in treating anxiety and agitation associated with dementia. Nevertheless, these drugs can cause acute extrapyramidal reactions or late-developing adverse effects such as tardive dyskinesia, consequently, their use is increasingly limited to acute situations and for brief durations. Newer, atypical antipsychotics, such as risperidone, 0.5 mg bid; olanzapine, 2.5 mg/d; and quetiapine, 100 mg bid, have a lower incidence of treatment-related adverse effects and are now considered the first-line treatments for anxiety and agitation. Short-term judicious use of benzodiazepines can also be beneficial as described previously. Finally, the newer anticonvulsants gabapentin, 100 to 300 mg tid, and lamotrigine, 25 to 100 mg bid, can be useful for treatment-resistant cases.

    Javaid I. Sheikh, MD
    Javaid I. Sheikh, MD, is associate professor, department of psychiatry and behavioral sciences, Stanford University School of Medicine, ...